- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,852.50 / $7,650.00 / $19,950.00
| Facility | | $3,852.50 | $7,650.00 | $19,950.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,325.00 / $4,150.00 / $4,250.00
| Professional | | $3,325.00 | $4,150.00 | $4,250.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,964.89 / $11,259.77 / $17,837.05
| Facility | | $2,964.89 | $11,259.77 | $17,837.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,748.71 / $5,452.67 / $26,411.38
| Professional | | $3,748.71 | $5,452.67 | $26,411.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,744.71 / $3,472.22 / $9,132.50
| Facility | | $2,744.71 | $3,472.22 | $9,132.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,350.00 / $5,000.00 / $9,810.81
| Facility | | $3,350.00 | $5,000.00 | $9,810.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,100.00 / $2,100.00 / $24,900.00
| Professional | | $2,100.00 | $2,100.00 | $24,900.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,100.00 / $2,100.00 / $3,000.00
| Professional | | $2,100.00 | $2,100.00 | $3,000.00 |