- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,785.51 / $1,785.51 / $8,500.00
| Facility | | $1,785.51 | $1,785.51 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,658.91 / $1,785.51 / $2,736.64
| Professional | | $1,658.91 | $1,785.51 | $2,736.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,518.57 / $3,823.67 / $4,517.68
| Professional | | $3,518.57 | $3,823.67 | $4,517.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,434.26 / $3,236.13 / $5,223.74
| Professional | | $2,434.26 | $3,236.13 | $5,223.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,785.51 / $2,468.42 / $5,356.53
| Facility | | $1,785.51 | $2,468.42 | $5,356.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,852.62 / $3,377.53 / $4,580.85
| Professional | | $1,852.62 | $3,377.53 | $4,580.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,978.58 / $3,597.42 / $4,580.85
| Professional | | $1,978.58 | $3,597.42 | $4,580.85 |