- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,098.25 / $2,098.25 / $8,500.00
| Facility | | $2,098.25 | $2,098.25 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,098.25 / $2,098.25 / $2,206.23
| Professional | | $2,098.25 | $2,098.25 | $2,206.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,156.78 / $4,511.93 / $5,330.87
| Professional | | $4,156.78 | $4,511.93 | $5,330.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,606.86 / $3,820.36 / $6,166.80
| Professional | | $2,606.86 | $3,820.36 | $6,166.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,098.25 / $2,371.44 / $6,294.75
| Facility | | $2,098.25 | $2,371.44 | $6,294.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,469.44 / $3,931.54 / $5,380.20
| Professional | | $1,469.44 | $3,931.54 | $5,380.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,303.13 / $4,187.50 / $5,380.20
| Professional | | $2,303.13 | $4,187.50 | $5,380.20 |