- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,961.98 / $7,439.04 / $11,494.80
| Facility | | $3,961.98 | $7,439.04 | $11,494.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,880.00 / $3,132.00 / $3,852.00
| Professional | | $2,880.00 | $3,132.00 | $3,852.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,500.00 / $4,500.00 / $4,500.00
| Professional | | $4,500.00 | $4,500.00 | $4,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,182.40 / $5,896.80 / $8,162.63
| Facility | | $3,182.40 | $5,896.80 | $8,162.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,880.00 / $3,600.00 / $4,843.12
| Facility | | $2,880.00 | $3,600.00 | $4,843.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,512.00 / $2,160.00 / $17,928.00
| Professional | | $1,512.00 | $2,160.00 | $17,928.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,512.00 / $2,160.00 / $5,400.00
| Professional | | $1,512.00 | $2,160.00 | $5,400.00 |