- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,450.00 / $2,730.00 / $16,598.40
| Facility | | $2,450.00 | $2,730.00 | $16,598.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,450.00 / $2,730.00 / $2,800.00
| Professional | | $2,450.00 | $2,730.00 | $2,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,500.00 / $3,500.00 / $4,786.25
| Professional | | $3,500.00 | $3,500.00 | $4,786.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,360.90 / $8,622.25 / $19,956.30
| Facility | | $6,360.90 | $8,622.25 | $19,956.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,690.60 / $3,500.00 / $4,422.60
| Facility | | $2,690.60 | $3,500.00 | $4,422.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.00 / $1,500.00 / $1,500.00
| Professional | | $1,500.00 | $1,500.00 | $1,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,470.00 / $1,925.00 / $3,187.14
| Professional | | $1,470.00 | $1,925.00 | $3,187.14 |