- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,676.47 / $1,676.47 / $8,500.00
| Facility | | $1,676.47 | $1,676.47 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,426.77 / $1,676.47 / $1,743.79
| Professional | | $1,426.77 | $1,676.47 | $1,743.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,290.81 / $3,578.11 / $4,227.56
| Professional | | $3,290.81 | $3,578.11 | $4,227.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,070.09 / $3,011.98 / $4,861.92
| Professional | | $2,070.09 | $3,011.98 | $4,861.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,676.47 / $2,302.28 / $5,029.41
| Facility | | $1,676.47 | $2,302.28 | $5,029.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,578.07 / $3,174.96 / $4,297.28
| Professional | | $1,578.07 | $3,174.96 | $4,297.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,859.91 / $3,202.23 / $4,297.28
| Professional | | $1,859.91 | $3,202.23 | $4,297.28 |