- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $1,047.13 / $1,047.13
| Facility | | $128.82 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,230.27
| Professional | | $1,047.13 | $1,047.13 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,122.02 / $1,202.26
| Facility | | $891.25 | $1,122.02 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,202.26
| Professional | | $1,122.02 | $1,122.02 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $169.82 / $223.87 / $309.03
| Facility | | $169.82 | $223.87 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $457.09 / $1,047.13
| Professional | | $309.03 | $457.09 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $977.24 / $1,659.59
| Facility | | $776.25 | $977.24 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $870.96 / $1,047.13
| Professional | | $302.00 | $870.96 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $363.08 / $1,047.13
| Professional | | $338.84 | $363.08 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $169.82 / $208.93 / $309.03
| Facility | | $169.82 | $208.93 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $457.09 / $2,187.76
| Professional | | $338.84 | $457.09 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $489.78 / $794.33
| Facility | | $302.00 | $489.78 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $302.00 / $1,000.00
| Professional | | $125.89 | $302.00 | $1,000.00 |