- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,105.43 / $1,105.43 / $8,500.00
| Facility | | $1,105.43 | $1,105.43 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,038.72 / $1,105.43 / $1,105.43
| Professional | | $1,038.72 | $1,105.43 | $1,105.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,119.89 / $2,306.84 / $2,765.40
| Professional | | $2,119.89 | $2,306.84 | $2,765.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,331.53 / $2,573.96 / $3,323.91
| Professional | | $1,331.53 | $2,573.96 | $3,323.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,105.43 / $1,541.78 / $3,316.29
| Facility | | $1,105.43 | $1,541.78 | $3,316.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.73 / $2,080.42 / $2,863.96
| Professional | | $1,148.73 | $2,080.42 | $2,863.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.73 / $2,215.88 / $2,863.96
| Professional | | $1,148.73 | $2,215.88 | $2,863.96 |