- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,165.39 / $1,172.56 / $1,172.56
| Facility | | $1,165.39 | $1,172.56 | $1,172.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,172.56 / $1,289.81
| Professional | | $1,172.56 | $1,172.56 | $1,289.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,128.33 / $1,327.45 / $1,327.45
| Facility | | $1,128.33 | $1,327.45 | $1,327.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.83 / $1,261.07 / $1,327.45
| Professional | | $237.83 | $1,261.07 | $1,327.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,172.56 / $1,172.56
| Facility | | $1,172.56 | $1,172.56 | $1,172.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.75 / $1,246.56 / $1,836.45
| Professional | | $110.75 | $1,246.56 | $1,836.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $215.47 / $1,431.00 / $2,214.23
| Facility | | $215.47 | $1,431.00 | $2,214.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.39 / $1,165.39 / $1,242.89
| Professional | | $1,165.39 | $1,165.39 | $1,242.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.75 / $1,431.00 / $1,836.45
| Facility | | $110.75 | $1,431.00 | $1,836.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.75 / $1,398.47 / $1,836.45
| Professional | | $110.75 | $1,398.47 | $1,836.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,113.93 / $1,172.56 / $1,289.82
| Professional | | $1,113.93 | $1,172.56 | $1,289.82 |