- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,615.78 / $1,615.78 / $8,500.00
| Facility | | $1,615.78 | $1,615.78 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,492.74 / $1,600.49 / $1,615.78
| Professional | | $1,492.74 | $1,600.49 | $1,615.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,121.92 / $3,434.27 / $4,026.87
| Professional | | $3,121.92 | $3,434.27 | $4,026.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,954.87 / $3,905.57 / $5,202.22
| Professional | | $1,954.87 | $3,905.57 | $5,202.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,615.78 / $2,173.52 / $2,746.83
| Facility | | $1,615.78 | $2,173.52 | $2,746.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,657.60 / $2,899.89 / $4,206.56
| Professional | | $1,657.60 | $2,899.89 | $4,206.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,657.60 / $2,872.04 / $3,658.77
| Professional | | $1,657.60 | $2,872.04 | $3,658.77 |