- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,172.56 / $1,172.56
| Facility | | $1,172.56 | $1,172.56 | $1,172.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,172.56 / $1,184.28
| Professional | | $1,172.56 | $1,172.56 | $1,184.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,057.41 / $1,189.42 / $1,288.01
| Professional | | $1,057.41 | $1,189.42 | $1,288.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,657.60 / $1,657.60 / $1,906.23
| Facility | | $1,657.60 | $1,657.60 | $1,906.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.40 / $1,172.56 / $1,323.00
| Professional | | $1,058.40 | $1,172.56 | $1,323.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $276.56 / $1,165.39 / $2,110.61
| Facility | | $276.56 | $1,165.39 | $2,110.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.39 / $1,165.39 / $1,305.24
| Professional | | $1,165.39 | $1,165.39 | $1,305.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,172.56 / $1,273.46
| Professional | | $1,172.56 | $1,172.56 | $1,273.46 |