- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,070.42 / $1,070.42 / $2,300.00
| Facility | | $1,070.42 | $1,070.42 | $2,300.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $968.80 / $1,083.48 / $1,205.82
| Professional | | $968.80 | $1,083.48 | $1,205.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,245.83 / $1,245.83 / $1,245.83
| Facility | | $1,245.83 | $1,245.83 | $1,245.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,201.73 / $1,201.73 / $1,201.73
| Facility | | $1,201.73 | $1,201.73 | $1,201.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,029.36 / $1,508.17 / $6,417.60
| Professional | | $1,029.36 | $1,508.17 | $6,417.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $859.42 / $1,181.70 / $1,910.22
| Professional | | $859.42 | $1,181.70 | $1,910.22 |