- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,592.00 / $2,592.00 / $5,378.40
| Facility | | $2,592.00 | $2,592.00 | $5,378.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,154.60 / $2,592.00 / $2,754.00
| Professional | | $2,154.60 | $2,592.00 | $2,754.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,461.91 / $4,509.85 / $8,505.74
| Facility | | $2,461.91 | $4,509.85 | $8,505.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,592.00 / $3,240.00 / $4,860.00
| Facility | | $2,592.00 | $3,240.00 | $4,860.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,106.00 / $2,106.00 / $3,240.00
| Professional | | $2,106.00 | $2,106.00 | $3,240.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,240.00 / $4,957.20 / $6,204.60
| Professional | | $3,240.00 | $4,957.20 | $6,204.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,620.00 / $1,944.00 / $3,337.20
| Professional | | $1,620.00 | $1,944.00 | $3,337.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,637.60 / $15,390.00 / $15,390.00
| Facility | | $5,637.60 | $15,390.00 | $15,390.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,200.00 / $16,200.00 / $24,300.00
| Professional | | $16,200.00 | $16,200.00 | $24,300.00 |