- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,750.86 / $1,750.86 / $8,500.00
| Facility | | $1,750.86 | $1,750.86 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,486.68 / $1,724.25 / $1,813.66
| Professional | | $1,486.68 | $1,724.25 | $1,813.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,515.13 / $3,866.82 / $4,534.05
| Professional | | $3,515.13 | $3,866.82 | $4,534.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,780.44 / $4,225.41 / $5,628.25
| Professional | | $1,780.44 | $4,225.41 | $5,628.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,208.73 / $1,750.86 / $2,955.73
| Facility | | $1,208.73 | $1,750.86 | $2,955.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,851.04 / $3,264.09 / $4,520.14
| Professional | | $1,851.04 | $3,264.09 | $4,520.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,851.04 / $3,264.09 / $4,520.14
| Professional | | $1,851.04 | $3,264.09 | $4,520.14 |