- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,370.73 / $1,370.73 / $1,370.73
| Facility | | $1,370.73 | $1,370.73 | $1,370.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,370.73 / $1,570.20 / $1,784.31
| Professional | | $1,370.73 | $1,570.20 | $1,784.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,346.65 / $1,427.45 / $1,427.45
| Facility | | $1,346.65 | $1,427.45 | $1,427.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,427.45 / $1,427.45
| Professional | | $1,427.45 | $1,427.45 | $1,427.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,370.73 / $1,784.31 / $2,283.92
| Facility | | $1,370.73 | $1,784.31 | $2,283.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,498.82 / $1,784.31
| Professional | | $1,427.45 | $1,498.82 | $1,784.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $2,149.98 / $2,704.83
| Professional | | $30.00 | $2,149.98 | $2,704.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,712.94 / $1,712.94 / $1,712.94
| Professional | | $1,712.94 | $1,712.94 | $1,712.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,427.45 / $1,427.45
| Professional | | $1,427.45 | $1,427.45 | $1,427.45 |