- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,641.25 / $2,641.25 / $8,500.00
| Facility | | $2,641.25 | $2,641.25 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,287.16 / $2,518.56 / $3,563.55
| Professional | | $2,287.16 | $2,518.56 | $3,563.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,610.05 / $3,826.66 / $4,278.97
| Professional | | $3,610.05 | $3,826.66 | $4,278.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,792.08 / $6,141.27 / $7,930.55
| Professional | | $3,792.08 | $6,141.27 | $7,930.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,641.25 / $3,085.77 / $4,490.13
| Facility | | $2,641.25 | $3,085.77 | $4,490.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,764.84 / $4,591.14 / $6,830.23
| Professional | | $2,764.84 | $4,591.14 | $6,830.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,586.67 / $4,132.81 / $5,700.61
| Professional | | $2,586.67 | $4,132.81 | $5,700.61 |