- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,908.65 / $1,908.65 / $1,908.65
| Facility | | $1,908.65 | $1,908.65 | $1,908.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,670.07 / $1,908.65
| Professional | | $1,590.54 | $1,670.07 | $1,908.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,794.23 / $1,794.23 / $1,794.23
| Facility | | $1,794.23 | $1,794.23 | $1,794.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,794.23 / $1,794.23 / $1,923.60
| Professional | | $1,794.23 | $1,794.23 | $1,923.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,500.51 / $1,590.54 / $1,590.54
| Facility | | $1,500.51 | $1,590.54 | $1,590.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $1,725.59
| Professional | | $1,590.54 | $1,590.54 | $1,725.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,463.30 / $1,590.54 / $1,829.12
| Professional | | $1,463.30 | $1,590.54 | $1,829.12 |