- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,264.77 / $1,264.77 / $8,500.00
| Facility | | $1,264.77 | $1,264.77 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,166.36 / $1,260.88 / $1,310.81
| Professional | | $1,166.36 | $1,260.88 | $1,310.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,561.06 / $2,817.29 / $3,303.42
| Professional | | $2,561.06 | $2,817.29 | $3,303.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,424.18 / $3,100.49 / $4,129.85
| Professional | | $1,424.18 | $3,100.49 | $4,129.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,264.77 / $1,755.79 / $2,546.54
| Facility | | $1,264.77 | $1,755.79 | $2,546.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,332.43 / $2,320.21 / $3,269.87
| Professional | | $1,332.43 | $2,320.21 | $3,269.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,332.43 / $2,320.21 / $2,729.75
| Professional | | $1,332.43 | $2,320.21 | $2,729.75 |