- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,220.06 / $1,220.06 / $8,500.00
| Facility | | $1,220.06 | $1,220.06 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,220.06 / $1,220.06 / $2,209.76
| Professional | | $1,220.06 | $1,220.06 | $2,209.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,803.00 / $1,803.00 / $2,253.75
| Professional | | $1,803.00 | $1,803.00 | $2,253.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,220.06 / $2,074.10 / $3,660.18
| Facility | | $1,220.06 | $2,074.10 | $3,660.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,997.67 / $3,763.23 / $4,507.14
| Professional | | $1,997.67 | $3,763.23 | $4,507.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,336.87 / $3,819.38 / $4,507.14
| Professional | | $2,336.87 | $3,819.38 | $4,507.14 |