- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,033.82 / $1,260.21 / $1,600.00
| Facility | | $1,033.82 | $1,260.21 | $1,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $960.00 / $1,214.63 / $1,262.66
| Professional | | $960.00 | $1,214.63 | $1,262.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,403.49 / $1,568.61 / $1,651.17
| Facility | | $1,403.49 | $1,568.61 | $1,651.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,387.54 / $1,387.54 / $1,387.54
| Professional | | $1,387.54 | $1,387.54 | $1,387.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,238.93 / $1,238.93 / $1,238.93
| Facility | | $1,238.93 | $1,238.93 | $1,238.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.63 / $1,238.93 / $1,518.28
| Professional | | $1,214.63 | $1,238.93 | $1,518.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,214.63 / $1,238.93 / $5,203.28
| Facility | | $1,214.63 | $1,238.93 | $5,203.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,032.44 / $1,214.63 / $1,340.47
| Professional | | $1,032.44 | $1,214.63 | $1,340.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $485.85 / $1,214.63 / $1,367.31
| Professional | | $485.85 | $1,214.63 | $1,367.31 |