- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,400.00 / $5,280.00 / $5,280.00
| Facility | | $4,400.00 | $5,280.00 | $5,280.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,752.00 / $19,800.00 / $95,040.00
| Facility | | $4,752.00 | $19,800.00 | $95,040.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,224.00 / $4,752.00 / $119,998.80
| Professional | | $4,224.00 | $4,752.00 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,860.00 / $4,224.00 / $10,559.12
| Facility | | $2,860.00 | $4,224.00 | $10,559.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,044.92 / $5,056.14 / $16,966.40
| Professional | | $4,044.92 | $5,056.14 | $16,966.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,478.40 / $1,584.00 / $4,752.00
| Professional | | $1,478.40 | $1,584.00 | $4,752.00 |