- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,500.00 / $4,500.00 / $5,519.00
| Facility | | $4,500.00 | $4,500.00 | $5,519.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,140.38 / $2,169.71 / $2,380.96
| Professional | | $2,140.38 | $2,169.71 | $2,380.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,462.46 / $2,268.80 / $2,777.23
| Facility | | $1,462.46 | $2,268.80 | $2,777.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,728.36 / $1,728.36 / $1,728.36
| Professional | | $1,728.36 | $1,728.36 | $1,728.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $2,326.64 / $3,500.00
| Professional | | $30.00 | $2,326.64 | $3,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,127.84 / $9,395.29 / $9,395.29
| Professional | | $3,127.84 | $9,395.29 | $9,395.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,700.00 / $15,298.00 / $26,104.00
| Facility | | $3,700.00 | $15,298.00 | $26,104.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,125.99 / $1,755.00 / $2,947.53
| Professional | | $1,125.99 | $1,755.00 | $2,947.53 |