- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.81 / $1,275.81 / $8,500.00
| Facility | | $1,275.81 | $1,275.81 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.60 / $1,264.23 / $1,296.34
| Professional | | $1,165.60 | $1,264.23 | $1,296.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,533.71 / $2,792.70 / $3,274.59
| Professional | | $2,533.71 | $2,792.70 | $3,274.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,547.67 / $3,092.05 / $4,118.62
| Professional | | $1,547.67 | $3,092.05 | $4,118.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.81 / $1,561.13 / $2,168.88
| Facility | | $1,275.81 | $1,561.13 | $2,168.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,336.40 / $2,248.90 / $3,303.52
| Professional | | $1,336.40 | $2,248.90 | $3,303.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,336.40 / $2,248.90 / $2,940.08
| Professional | | $1,336.40 | $2,248.90 | $2,940.08 |