- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,287.50 / $4,750.00 / $11,410.50
| Facility | | $3,287.50 | $4,750.00 | $11,410.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,650.00 / $3,287.50 / $3,500.00
| Professional | | $2,650.00 | $3,287.50 | $3,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,163.19 / $7,337.50 / $12,375.00
| Facility | | $2,163.19 | $7,337.50 | $12,375.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,550.00 / $4,738.02 / $6,156.47
| Professional | | $2,550.00 | $4,738.02 | $6,156.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,250.00 / $13,863.89 / $28,698.23
| Facility | | $3,250.00 | $13,863.89 | $28,698.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,500.00 / $7,862.50 / $12,350.00
| Professional | | $3,500.00 | $7,862.50 | $12,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,300.00 / $3,087.00 / $8,774.50
| Professional | | $2,300.00 | $3,087.00 | $8,774.50 |