- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,836.80 / $5,836.80 / $8,320.00
| Facility | | $5,836.80 | $5,836.80 | $8,320.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,240.00 / $6,240.00 / $6,240.00
| Professional | | $2,240.00 | $6,240.00 | $6,240.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,480.00 / $12,480.00 / $12,480.00
| Facility | | $12,480.00 | $12,480.00 | $12,480.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,891.20 / $6,240.00 / $6,864.00
| Facility | | $3,891.20 | $6,240.00 | $6,864.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,200.00 / $3,200.00 / $3,840.00
| Professional | | $3,200.00 | $3,200.00 | $3,840.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $78.00 / $6,240.00
| Professional | | $30.00 | $78.00 | $6,240.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,800.00 / $6,400.00 / $11,520.00
| Facility | | $4,800.00 | $6,400.00 | $11,520.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,782.47 / $4,782.47 / $4,942.47
| Professional | | $4,782.47 | $4,782.47 | $4,942.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,344.00 / $1,344.00 / $4,800.00
| Professional | | $1,344.00 | $1,344.00 | $4,800.00 |