- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,577.92 / $1,577.92 / $8,500.00
| Facility | | $1,577.92 | $1,577.92 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,577.92 / $1,577.92 / $1,649.14
| Professional | | $1,577.92 | $1,577.92 | $1,649.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,098.96 / $3,348.69 / $3,956.51
| Professional | | $3,098.96 | $3,348.69 | $3,956.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,964.68 / $2,852.53 / $4,604.53
| Professional | | $1,964.68 | $2,852.53 | $4,604.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,577.92 / $2,125.71 / $4,733.76
| Facility | | $1,577.92 | $2,125.71 | $4,733.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,622.24 / $3,004.64 / $4,047.66
| Professional | | $1,622.24 | $3,004.64 | $4,047.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,760.14 / $3,007.41 / $4,047.66
| Professional | | $1,760.14 | $3,007.41 | $4,047.66 |