- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,609.91 / $2,609.91 / $8,500.00
| Facility | | $2,609.91 | $2,609.91 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,413.21 / $2,568.80 / $2,707.43
| Professional | | $2,413.21 | $2,568.80 | $2,707.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,233.24 / $5,756.82 / $6,750.18
| Professional | | $5,233.24 | $5,756.82 | $6,750.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,174.07 / $6,282.84 / $8,368.75
| Professional | | $3,174.07 | $6,282.84 | $8,368.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,609.91 / $3,218.08 / $4,436.85
| Facility | | $2,609.91 | $3,218.08 | $4,436.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,761.58 / $4,866.81 / $6,735.69
| Professional | | $2,761.58 | $4,866.81 | $6,735.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,761.58 / $4,866.81 / $6,735.69
| Professional | | $2,761.58 | $4,866.81 | $6,735.69 |