- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,380.38 / $8,511.38
| Facility | | $1,258.93 | $1,380.38 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,380.38 / $1,380.38
| Professional | | $1,000.00 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,818.38 / $3,388.44
| Professional | | $2,290.87 | $2,818.38 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,819.70 / $2,398.83
| Facility | | $1,380.38 | $1,819.70 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,398.83 / $3,467.37
| Professional | | $1,348.96 | $2,398.83 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $24,547.09
| Facility | | $1,819.70 | $2,041.74 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,089.30 / $2,884.03
| Professional | | $1,348.96 | $2,089.30 | $2,884.03 |