- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,282.74 / $1,282.74 / $8,500.00
| Facility | | $1,282.74 | $1,282.74 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.09 / $1,282.74 / $1,282.74
| Professional | | $1,093.09 | $1,282.74 | $1,282.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,821.88 / $5,821.88 / $7,277.34
| Professional | | $5,821.88 | $5,821.88 | $7,277.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,282.74 / $1,581.63 / $3,848.22
| Facility | | $1,282.74 | $1,581.63 | $3,848.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,154.79 / $2,195.28 / $14,605.42
| Professional | | $1,154.79 | $2,195.28 | $14,605.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,286.01 / $2,338.19 / $14,605.42
| Professional | | $1,286.01 | $2,338.19 | $14,605.42 |