- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,975.00 / $4,705.13 / $8,120.00
| Facility | | $2,975.00 | $4,705.13 | $8,120.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,975.00 / $3,045.00 / $4,025.00
| Professional | | $2,975.00 | $3,045.00 | $4,025.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.16 / $3,123.75 / $6,199.05
| Professional | | $239.16 | $3,123.75 | $6,199.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,820.72 / $6,759.03 / $8,342.43
| Facility | | $4,820.72 | $6,759.03 | $8,342.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,062.01 / $4,062.01 / $4,062.01
| Professional | | $4,062.01 | $4,062.01 | $4,062.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,975.00 / $4,200.00 / $16,625.00
| Facility | | $2,975.00 | $4,200.00 | $16,625.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,470.00 / $2,100.00 / $17,430.00
| Professional | | $1,470.00 | $2,100.00 | $17,430.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,470.00 / $2,100.00 / $3,958.50
| Professional | | $1,470.00 | $2,100.00 | $3,958.50 |