- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,064.60 / $2,064.60 / $8,500.00
| Facility | | $2,064.60 | $2,064.60 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,908.89 / $2,025.72 / $2,137.13
| Professional | | $1,908.89 | $2,025.72 | $2,137.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,132.54 / $4,546.00 / $5,330.43
| Professional | | $4,132.54 | $4,546.00 | $5,330.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,632.86 / $4,958.76 / $6,605.08
| Professional | | $2,632.86 | $4,958.76 | $6,605.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,064.60 / $2,577.48 / $3,509.82
| Facility | | $2,064.60 | $2,577.48 | $3,509.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,217.10 / $3,841.47 / $5,327.76
| Professional | | $2,217.10 | $3,841.47 | $5,327.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,185.23 / $3,787.51 / $4,807.51
| Professional | | $2,185.23 | $3,787.51 | $4,807.51 |