- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,942.40 / $1,942.40 / $8,500.00
| Facility | | $1,942.40 | $1,942.40 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,779.01 / $1,942.40 / $2,022.93
| Professional | | $1,779.01 | $1,942.40 | $2,022.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,829.80 / $4,149.89 / $4,903.14
| Professional | | $3,829.80 | $4,149.89 | $4,903.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,538.56 / $3,495.57 / $5,642.53
| Professional | | $2,538.56 | $3,495.57 | $5,642.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,942.40 / $2,671.02 / $5,827.20
| Facility | | $1,942.40 | $2,671.02 | $5,827.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,999.05 / $3,678.61 / $4,979.60
| Professional | | $1,999.05 | $3,678.61 | $4,979.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,350.86 / $3,918.10 / $4,546.93
| Professional | | $2,350.86 | $3,918.10 | $4,546.93 |