- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,215.25 / $1,215.25 / $2,521.64
| Facility | | $1,215.25 | $1,215.25 | $2,521.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,010.17 / $1,215.25 / $1,291.20
| Professional | | $1,010.17 | $1,215.25 | $1,291.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,154.26 / $1,481.09 / $3,988.20
| Facility | | $1,154.26 | $1,481.09 | $3,988.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,215.25 / $1,519.06 / $2,278.59
| Facility | | $1,215.25 | $1,519.06 | $2,278.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $987.39 / $987.39 / $1,519.06
| Professional | | $987.39 | $987.39 | $1,519.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,519.06 / $2,324.16 / $2,909.00
| Professional | | $1,519.06 | $2,324.16 | $2,909.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,519.06 / $1,792.49 / $1,822.87
| Facility | | $1,519.06 | $1,792.49 | $1,822.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $759.53 / $911.44 / $1,564.63
| Professional | | $759.53 | $911.44 | $1,564.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,643.16 / $7,215.54 / $7,215.54
| Facility | | $2,643.16 | $7,215.54 | $7,215.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,564.92 / $7,564.92 / $11,392.95
| Professional | | $7,564.92 | $7,564.92 | $11,392.95 |