- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,183.17 / $2,183.17 / $8,500.00
| Facility | | $2,183.17 | $2,183.17 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,017.54 / $2,183.17 / $3,511.51
| Professional | | $2,017.54 | $2,183.17 | $3,511.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,640.22 / $5,114.52 / $5,997.06
| Professional | | $4,640.22 | $5,114.52 | $5,997.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,603.25 / $5,200.96 / $6,927.69
| Professional | | $2,603.25 | $5,200.96 | $6,927.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,183.17 / $2,756.36 / $3,728.92
| Facility | | $2,183.17 | $2,756.36 | $3,728.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,414.76 / $4,054.98 / $5,564.42
| Professional | | $2,414.76 | $4,054.98 | $5,564.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,414.76 / $4,005.03 / $5,564.42
| Professional | | $2,414.76 | $4,005.03 | $5,564.42 |