- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,329.78 / $1,329.78 / $1,400.00
| Facility | | $1,329.78 | $1,329.78 | $1,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,273.85 / $1,329.78 / $1,553.82
| Professional | | $1,273.85 | $1,329.78 | $1,553.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,403.64 / $1,605.06 / $1,748.74
| Facility | | $1,403.64 | $1,605.06 | $1,748.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,554.43 / $1,554.43 / $1,554.43
| Professional | | $1,554.43 | $1,554.43 | $1,554.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,505.75 / $1,505.75 / $1,505.75
| Facility | | $1,505.75 | $1,505.75 | $1,505.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.29 / $1,943.04 / $7,956.34
| Professional | | $1,263.29 | $1,943.04 | $7,956.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,072.57 / $1,526.15 / $2,246.02
| Professional | | $1,072.57 | $1,526.15 | $2,246.02 |