- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,655.51 / $1,655.51 / $8,500.00
| Facility | | $1,655.51 | $1,655.51 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,354.63 / $1,650.33 / $1,940.23
| Professional | | $1,354.63 | $1,650.33 | $1,940.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,550.22 / $3,913.11 / $4,588.33
| Professional | | $3,550.22 | $3,913.11 | $4,588.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,027.52 / $4,050.72 / $5,395.57
| Professional | | $2,027.52 | $4,050.72 | $5,395.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,655.51 / $1,980.90 / $2,883.02
| Facility | | $1,655.51 | $1,980.90 | $2,883.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,785.79 / $2,976.32 / $4,233.88
| Professional | | $1,785.79 | $2,976.32 | $4,233.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,785.79 / $2,976.32 / $4,154.89
| Professional | | $1,785.79 | $2,976.32 | $4,154.89 |