- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,828.20 / $1,828.20 / $8,500.00
| Facility | | $1,828.20 | $1,828.20 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.15 / $1,828.20 / $2,769.10
| Professional | | $1,808.15 | $1,828.20 | $2,769.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,597.38 / $3,898.74 / $4,606.39
| Professional | | $3,597.38 | $3,898.74 | $4,606.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,358.10 / $3,277.96 / $5,291.25
| Professional | | $2,358.10 | $3,277.96 | $5,291.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,828.20 / $2,506.67 / $5,484.60
| Facility | | $1,828.20 | $2,506.67 | $5,484.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,872.12 / $3,465.67 / $4,685.13
| Professional | | $1,872.12 | $3,465.67 | $4,685.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,030.22 / $3,691.30 / $4,685.13
| Professional | | $2,030.22 | $3,691.30 | $4,685.13 |