- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,366.53 / $8,500.00
| Facility | | $2,000.00 | $2,366.53 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,366.53 / $2,366.53 / $2,936.99
| Professional | | $2,366.53 | $2,366.53 | $2,936.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $292.35 / $2,366.53 / $7,099.59
| Facility | | $292.35 | $2,366.53 | $7,099.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,119.46 / $6,663.67 / $9,169.74
| Professional | | $4,119.46 | $6,663.67 | $9,169.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,143.48 / $3,143.48 / $3,143.48
| Facility | | $3,143.48 | $3,143.48 | $3,143.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,903.63 / $7,097.50 / $9,169.74
| Professional | | $3,903.63 | $7,097.50 | $9,169.74 |