- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,123.75 / $4,940.39 / $8,526.00
| Facility | | $3,123.75 | $4,940.39 | $8,526.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,123.75 / $3,197.25 / $3,564.75
| Professional | | $3,123.75 | $3,197.25 | $3,564.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.00 / $3,724.41 / $6,509.01
| Professional | | $1,500.00 | $3,724.41 | $6,509.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,061.76 / $7,096.98 / $8,759.54
| Facility | | $5,061.76 | $7,096.98 | $8,759.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.14 / $4,265.14 / $4,265.14
| Professional | | $4,265.14 | $4,265.14 | $4,265.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,123.75 / $4,410.00 / $17,456.25
| Facility | | $3,123.75 | $4,410.00 | $17,456.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,543.50 / $2,205.00 / $18,301.50
| Professional | | $1,543.50 | $2,205.00 | $18,301.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,543.50 / $2,205.00 / $4,156.43
| Professional | | $1,543.50 | $2,205.00 | $4,156.43 |