- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,505.40 / $1,505.40 / $8,500.00
| Facility | | $1,505.40 | $1,505.40 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,401.70 / $1,505.40 / $2,378.12
| Professional | | $1,401.70 | $1,505.40 | $2,378.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,220.55 / $3,542.77 / $4,154.09
| Professional | | $3,220.55 | $3,542.77 | $4,154.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,818.01 / $3,632.15 / $4,838.03
| Professional | | $1,818.01 | $3,632.15 | $4,838.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,505.40 / $1,982.89 / $2,604.94
| Facility | | $1,505.40 | $1,982.89 | $2,604.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,656.87 / $2,848.34 / $3,843.63
| Professional | | $1,656.87 | $2,848.34 | $3,843.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,656.87 / $2,761.66 / $3,645.11
| Professional | | $1,656.87 | $2,761.66 | $3,645.11 |