- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,565.78 / $6,695.14 / $10,345.29
| Facility | | $3,565.78 | $6,695.14 | $10,345.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,430.00 / $2,818.80 / $3,466.80
| Professional | | $2,430.00 | $2,818.80 | $3,466.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,304.80 / $3,304.80 / $3,304.80
| Professional | | $3,304.80 | $3,304.80 | $3,304.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,864.16 / $5,307.12 / $7,346.60
| Facility | | $2,864.16 | $5,307.12 | $7,346.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,592.00 / $3,240.00 / $4,358.81
| Facility | | $2,592.00 | $3,240.00 | $4,358.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.80 / $1,944.00 / $16,200.00
| Professional | | $1,360.80 | $1,944.00 | $16,200.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,910.00 / $8,910.00 / $8,910.00
| Facility | | $8,910.00 | $8,910.00 | $8,910.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.80 / $1,944.00 / $4,860.00
| Professional | | $1,360.80 | $1,944.00 | $4,860.00 |