- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,203.33 / $1,203.33 / $8,500.00
| Facility | | $1,203.33 | $1,203.33 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.77 / $1,199.39 / $1,245.43
| Professional | | $1,112.77 | $1,199.39 | $1,245.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,436.13 / $2,679.86 / $3,142.28
| Professional | | $2,436.13 | $2,679.86 | $3,142.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,477.13 / $2,951.12 / $3,930.90
| Professional | | $1,477.13 | $2,951.12 | $3,930.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,203.33 / $1,541.55 / $2,057.63
| Facility | | $1,203.33 | $1,541.55 | $2,057.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,267.47 / $2,207.53 / $3,111.30
| Professional | | $1,267.47 | $2,207.53 | $3,111.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,267.47 / $2,287.61 / $3,111.30
| Professional | | $1,267.47 | $2,287.61 | $3,111.30 |