- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,625.00 / $3,500.00 / $8,400.00
| Facility | | $2,625.00 | $3,500.00 | $8,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,590.00 / $3,072.00 / $3,500.00
| Professional | | $2,590.00 | $3,072.00 | $3,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,325.00 / $3,325.00 / $3,325.00
| Professional | | $3,325.00 | $3,325.00 | $3,325.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,275.00 / $2,275.00 / $9,350.25
| Facility | | $2,275.00 | $2,275.00 | $9,350.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,263.10 / $4,263.10 / $5,107.68
| Professional | | $4,263.10 | $4,263.10 | $5,107.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,590.00 / $3,500.00 / $5,880.00
| Facility | | $2,590.00 | $3,500.00 | $5,880.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,470.00 / $1,470.00 / $5,250.00
| Professional | | $1,470.00 | $1,470.00 | $5,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,470.00 / $1,470.00 / $3,500.00
| Professional | | $1,470.00 | $1,470.00 | $3,500.00 |