- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,920.00 / $2,400.00 / $13,856.00
| Facility | | $1,920.00 | $2,400.00 | $13,856.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,744.00 / $2,240.00 / $2,880.00
| Professional | | $1,744.00 | $2,240.00 | $2,880.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,607.14 / $2,289.35 / $12,031.92
| Facility | | $1,607.14 | $2,289.35 | $12,031.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,897.99 / $3,897.99 / $4,670.24
| Professional | | $3,897.99 | $3,897.99 | $4,670.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,920.00 / $1,920.00 / $2,720.00
| Professional | | $1,920.00 | $1,920.00 | $2,720.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $70.00
| Professional | | $50.00 | $50.00 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,200.00 / $3,200.00 / $4,800.00
| Facility | | $3,200.00 | $3,200.00 | $4,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,120.00 / $1,344.00 / $4,307.20
| Professional | | $1,120.00 | $1,344.00 | $4,307.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,920.00 / $1,920.00 / $1,920.00
| Professional | | $1,920.00 | $1,920.00 | $1,920.00 |