- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,278.96 / $1,278.96 / $8,500.00
| Facility | | $1,278.96 | $1,278.96 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,278.96 / $1,278.96 / $1,289.45
| Professional | | $1,278.96 | $1,278.96 | $1,289.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,544.51 / $2,765.53 / $3,315.27
| Professional | | $2,544.51 | $2,765.53 | $3,315.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,594.71 / $2,993.03 / $3,865.06
| Professional | | $1,594.71 | $2,993.03 | $3,865.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,278.96 / $1,655.62 / $3,836.88
| Facility | | $1,278.96 | $1,655.62 | $3,836.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,361.30 / $2,383.15 / $3,293.38
| Professional | | $1,361.30 | $2,383.15 | $3,293.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,361.30 / $2,538.30 / $3,293.38
| Professional | | $1,361.30 | $2,538.30 | $3,293.38 |