- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $900.00 / $1,831.00 / $2,825.00
| Facility | | $900.00 | $1,831.00 | $2,825.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,434.31 / $2,020.63 / $4,404.71
| Professional | | $1,434.31 | $2,020.63 | $4,404.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,361.50 / $4,361.50 / $4,361.50
| Professional | | $4,361.50 | $4,361.50 | $4,361.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $21.25 / $50.00
| Professional | | $17.00 | $21.25 | $50.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,185.00 / $5,800.00 / $14,043.00
| Facility | | $1,185.00 | $5,800.00 | $14,043.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,411.58 / $2,415.44 / $4,773.22
| Professional | | $1,411.58 | $2,415.44 | $4,773.22 |