- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,400.05 / $2,400.05 / $8,500.00
| Facility | | $2,400.05 | $2,400.05 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,294.21 / $2,400.05 / $2,400.05
| Professional | | $2,294.21 | $2,400.05 | $2,400.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,997.01 / $5,450.73 / $6,534.24
| Professional | | $4,997.01 | $5,450.73 | $6,534.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,093.64 / $5,520.44 / $7,128.85
| Professional | | $3,093.64 | $5,520.44 | $7,128.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,400.05 / $3,409.50 / $7,200.15
| Facility | | $2,400.05 | $3,409.50 | $7,200.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,470.61 / $4,402.89 / $6,115.03
| Professional | | $2,470.61 | $4,402.89 | $6,115.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,657.28 / $5,178.06 / $6,115.03
| Professional | | $2,657.28 | $5,178.06 | $6,115.03 |