- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,101.46 / $2,101.46 / $5,403.76
| Facility | | $2,101.46 | $2,101.46 | $5,403.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,101.46 / $2,101.46 / $2,500.00
| Professional | | $2,101.46 | $2,101.46 | $2,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,518.89 / $6,049.21 / $6,754.70
| Professional | | $4,518.89 | $6,049.21 | $6,754.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,449.79 / $3,449.79 / $5,064.45
| Professional | | $3,449.79 | $3,449.79 | $5,064.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,500.00 / $2,101.46 / $5,403.76
| Facility | | $1,500.00 | $2,101.46 | $5,403.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,531.07 / $3,602.51 / $6,004.18
| Professional | | $1,531.07 | $3,602.51 | $6,004.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.88 / $3,062.13 / $5,103.55
| Professional | | $1,260.88 | $3,062.13 | $5,103.55 |