- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,665.41 / $1,665.41 / $8,500.00
| Facility | | $1,665.41 | $1,665.41 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,665.41 / $1,665.41 / $1,741.03
| Professional | | $1,665.41 | $1,665.41 | $1,741.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,278.59 / $3,565.48 / $4,212.64
| Professional | | $3,278.59 | $3,565.48 | $4,212.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.41 / $3,013.94 / $4,865.08
| Professional | | $2,238.41 | $3,013.94 | $4,865.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,665.41 / $2,299.38 / $4,996.22
| Facility | | $1,665.41 | $2,299.38 | $4,996.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,723.31 / $3,154.66 / $4,272.22
| Professional | | $1,723.31 | $3,154.66 | $4,272.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,848.02 / $3,700.62 / $4,289.93
| Professional | | $1,848.02 | $3,700.62 | $4,289.93 |