- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,275.00 / $3,325.00 / $15,155.00
| Facility | | $2,275.00 | $3,325.00 | $15,155.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,100.00 / $2,450.00 / $3,150.00
| Professional | | $2,100.00 | $2,450.00 | $3,150.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,920.63 / $2,688.89 / $13,159.52
| Facility | | $1,920.63 | $2,688.89 | $13,159.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,047.50 / $4,263.10 / $5,107.68
| Professional | | $2,047.50 | $4,263.10 | $5,107.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,100.00 / $2,100.00 / $2,975.00
| Professional | | $2,100.00 | $2,100.00 | $2,975.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,225.00 / $1,470.00 / $7,700.00
| Professional | | $1,225.00 | $1,470.00 | $7,700.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,100.00 / $2,100.00 / $2,100.00
| Professional | | $2,100.00 | $2,100.00 | $2,100.00 |