- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,753.88 / $1,753.88 / $8,500.00
| Facility | | $1,753.88 | $1,753.88 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,634.77 / $1,753.88 / $2,660.07
| Professional | | $1,634.77 | $1,753.88 | $2,660.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,440.07 / $3,740.18 / $4,419.05
| Professional | | $3,440.07 | $3,740.18 | $4,419.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,430.19 / $3,148.56 / $5,082.39
| Professional | | $2,430.19 | $3,148.56 | $5,082.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,753.88 / $2,406.41 / $5,261.64
| Facility | | $1,753.88 | $2,406.41 | $5,261.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,779.41 / $3,509.25 / $4,495.57
| Professional | | $1,779.41 | $3,509.25 | $4,495.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,055.75 / $3,737.72 / $4,495.57
| Professional | | $2,055.75 | $3,737.72 | $4,495.57 |