- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,179.85 / $1,179.85 / $8,500.00
| Facility | | $1,179.85 | $1,179.85 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,179.85 / $1,179.85 / $1,213.20
| Professional | | $1,179.85 | $1,179.85 | $1,213.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,330.03 / $2,527.13 / $2,985.82
| Professional | | $2,330.03 | $2,527.13 | $2,985.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,615.59 / $2,093.16 / $3,378.76
| Professional | | $1,615.59 | $2,093.16 | $3,378.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,179.85 / $1,610.48 / $3,539.58
| Facility | | $1,179.85 | $1,610.48 | $3,539.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.40 / $2,256.85 / $3,011.39
| Professional | | $1,288.40 | $2,256.85 | $3,011.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,322.08 / $2,403.78 / $2,804.45
| Professional | | $1,322.08 | $2,403.78 | $2,804.45 |