- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,843.11 / $1,843.11 / $8,500.00
| Facility | | $1,843.11 | $1,843.11 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,843.11 / $1,843.11 / $2,084.92
| Professional | | $1,843.11 | $1,843.11 | $2,084.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,917.37 / $3,152.82 / $3,651.28
| Professional | | $2,917.37 | $3,152.82 | $3,651.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,776.16 / $6,187.99 / $9,988.61
| Professional | | $4,776.16 | $6,187.99 | $9,988.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,843.11 / $2,258.17 / $5,529.33
| Facility | | $1,843.11 | $2,258.17 | $5,529.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,608.94 / $4,002.49 / $7,703.55
| Professional | | $1,608.94 | $4,002.49 | $7,703.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,541.46 / $3,802.44 / $7,703.55
| Professional | | $2,541.46 | $3,802.44 | $7,703.55 |