- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,506.62 / $1,506.62 / $9,500.00
| Facility | | $1,506.62 | $1,506.62 | $9,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,365.97 / $2,082.94 / $2,318.71
| Professional | | $1,365.97 | $2,082.94 | $2,318.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,506.62 / $2,811.73 / $3,854.56
| Facility | | $1,506.62 | $2,811.73 | $3,854.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,378.67 / $4,141.02 / $5,837.81
| Professional | | $2,378.67 | $4,141.02 | $5,837.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,485.19 / $4,210.25 / $5,837.81
| Professional | | $2,485.19 | $4,210.25 | $5,837.81 |