- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,325.00 / $3,325.00 / $8,881.50
| Facility | | $3,325.00 | $3,325.00 | $8,881.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,325.00 / $4,600.00 / $5,000.00
| Professional | | $3,325.00 | $4,600.00 | $5,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,608.76 / $5,212.00 / $17,300.00
| Facility | | $3,608.76 | $5,212.00 | $17,300.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,183.60 / $6,200.00
| Professional | | $2,000.00 | $2,183.60 | $6,200.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,000.00 / $7,250.00 / $10,746.47
| Facility | | $5,000.00 | $7,250.00 | $10,746.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,500.00 / $11,000.00 / $15,417.68
| Facility | | $6,500.00 | $11,000.00 | $15,417.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,200.00 / $12,100.00 / $28,143.04
| Professional | | $8,200.00 | $12,100.00 | $28,143.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,500.00 / $6,500.00 / $11,670.68
| Professional | | $4,500.00 | $6,500.00 | $11,670.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,050.00 / $7,000.00 / $9,250.00
| Professional | | $6,050.00 | $7,000.00 | $9,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,100.00 / $3,000.00 / $9,085.50
| Professional | | $2,100.00 | $3,000.00 | $9,085.50 |