- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,850.00 / $2,850.00 / $10,551.40
| Facility | | $2,850.00 | $2,850.00 | $10,551.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,850.00 / $2,850.00 / $2,850.00
| Professional | | $2,850.00 | $2,850.00 | $2,850.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,310.45 / $3,404.80 / $10,671.47
| Facility | | $3,310.45 | $3,404.80 | $10,671.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,779.71 / $4,158.78 / $7,086.09
| Professional | | $1,779.71 | $4,158.78 | $7,086.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,873.00 / $4,453.95 / $15,685.65
| Facility | | $3,873.00 | $4,453.95 | $15,685.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,737.83 / $4,406.00 / $4,683.46
| Professional | | $3,737.83 | $4,406.00 | $4,683.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,358.96 / $1,626.66 / $2,323.80
| Professional | | $1,358.96 | $1,626.66 | $2,323.80 |