- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,150.00 / $16,506.00 / $21,640.50
| Facility | | $3,150.00 | $16,506.00 | $21,640.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,150.00 / $3,150.00 / $3,150.00
| Professional | | $3,150.00 | $3,150.00 | $3,150.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,991.63 / $3,076.89 / $9,643.73
| Facility | | $2,991.63 | $3,076.89 | $9,643.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $4,200.00
| Professional | | $4,200.00 | $4,200.00 | $4,200.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,500.00 / $4,025.00 / $4,200.00
| Facility | | $3,500.00 | $4,025.00 | $4,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,151.08 / $3,536.78 / $4,368.74
| Professional | | $3,151.08 | $3,536.78 | $4,368.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,470.00 / $1,470.00 / $2,100.00
| Professional | | $1,470.00 | $1,470.00 | $2,100.00 |