- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,290.00 / $3,290.00 / $3,290.00
| Facility | | $3,290.00 | $3,290.00 | $3,290.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,793.73 / $2,345.00 / $3,290.00
| Professional | | $1,793.73 | $2,345.00 | $3,290.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,027.24 / $6,356.97 / $7,946.21
| Professional | | $5,027.24 | $6,356.97 | $7,946.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,303.30 / $3,963.05 / $6,425.30
| Facility | | $3,303.30 | $3,963.05 | $6,425.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,785.00 / $2,100.00 / $6,888.00
| Professional | | $1,785.00 | $2,100.00 | $6,888.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,550.00 / $7,670.55
| Facility | | $4,200.00 | $4,550.00 | $7,670.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,200.00 / $6,125.00 / $7,210.00
| Professional | | $4,200.00 | $6,125.00 | $7,210.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,005.00 / $8,432.54 / $9,615.20
| Professional | | $5,005.00 | $8,432.54 | $9,615.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,470.00 / $1,785.00 / $3,500.00
| Professional | | $1,470.00 | $1,785.00 | $3,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,500.00 / $3,500.00 / $3,500.00
| Professional | | $3,500.00 | $3,500.00 | $3,500.00 |