- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,700.00 / $4,700.00 / $4,700.00
| Facility | | $4,700.00 | $4,700.00 | $4,700.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,900.00 / $4,275.00 / $4,700.00
| Professional | | $3,900.00 | $4,275.00 | $4,700.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,181.55 / $9,081.10 / $11,351.38
| Professional | | $7,181.55 | $9,081.10 | $11,351.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,719.00 / $5,661.50 / $9,179.00
| Facility | | $4,719.00 | $5,661.50 | $9,179.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,550.00 / $3,000.00 / $8,943.89
| Professional | | $2,550.00 | $3,000.00 | $8,943.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,000.00 / $6,500.00 / $10,957.92
| Facility | | $6,000.00 | $6,500.00 | $10,957.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,000.00 / $8,750.00 / $10,300.00
| Professional | | $6,000.00 | $8,750.00 | $10,300.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,150.00 / $12,046.50 / $13,736.00
| Professional | | $7,150.00 | $12,046.50 | $13,736.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,100.00 / $2,550.00 / $5,000.00
| Professional | | $2,100.00 | $2,550.00 | $5,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,000.00 / $5,000.00 / $5,000.00
| Professional | | $5,000.00 | $5,000.00 | $5,000.00 |