- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,115.50 / $5,175.75 / $8,793.75
| Facility | | $3,115.50 | $5,175.75 | $8,793.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,512.50 / $2,512.50 / $2,512.50
| Professional | | $2,512.50 | $2,512.50 | $2,512.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,071.88 / $2,071.88 / $2,071.88
| Facility | | $2,071.88 | $2,071.88 | $2,071.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $861.93 / $861.93 / $1,077.41
| Professional | | $861.93 | $861.93 | $1,077.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $450.00 / $570.00 / $900.00
| Facility | | $450.00 | $570.00 | $900.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.00 / $750.00 / $3,000.00
| Professional | | $750.00 | $750.00 | $3,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,775.00 / $2,775.00 / $3,000.00
| Facility | | $2,775.00 | $2,775.00 | $3,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $675.00 / $1,125.00 / $3,000.00
| Professional | | $675.00 | $1,125.00 | $3,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $450.00 / $577.50 / $1,462.50
| Facility | | $450.00 | $577.50 | $1,462.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $712.50 / $750.00 / $2,062.50
| Professional | | $712.50 | $750.00 | $2,062.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $337.50 / $1,500.00 / $1,500.00
| Professional | | $337.50 | $1,500.00 | $1,500.00 |