- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,354.55 / $1,354.55 / $8,500.00
| Facility | | $1,354.55 | $1,354.55 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,164.50 / $1,352.06 / $1,393.50
| Professional | | $1,164.50 | $1,352.06 | $1,393.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,634.05 / $2,897.58 / $3,397.56
| Professional | | $2,634.05 | $2,897.58 | $3,397.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,652.85 / $3,302.18 / $4,398.51
| Professional | | $1,652.85 | $3,302.18 | $4,398.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,354.55 / $1,897.07 / $2,653.21
| Facility | | $1,354.55 | $1,897.07 | $2,653.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,388.01 / $2,447.88 / $3,528.53
| Professional | | $1,388.01 | $2,447.88 | $3,528.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,388.01 / $2,458.63 / $3,528.53
| Professional | | $1,388.01 | $2,458.63 | $3,528.53 |