- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,825.00 / $3,825.00 / $3,825.00
| Facility | | $3,825.00 | $3,825.00 | $3,825.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,600.00 / $3,825.00 / $4,275.00
| Professional | | $3,600.00 | $3,825.00 | $4,275.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $941.10 / $2,183.67 / $3,436.05
| Facility | | $941.10 | $2,183.67 | $3,436.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $940.43 / $3,750.00 / $6,662.78
| Professional | | $940.43 | $3,750.00 | $6,662.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,055.94 / $5,234.04 / $9,640.84
| Facility | | $3,055.94 | $5,234.04 | $9,640.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,825.00 / $3,825.00 / $3,825.00
| Facility | | $3,825.00 | $3,825.00 | $3,825.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,825.00 / $3,825.00 / $3,825.00
| Professional | | $3,825.00 | $3,825.00 | $3,825.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $959.24 / $4,146.34 / $8,090.00
| Facility | | $959.24 | $4,146.34 | $8,090.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,079.14 / $1,316.60 / $1,905.69
| Professional | | $1,079.14 | $1,316.60 | $1,905.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,825.00 / $3,825.00 / $5,814.00
| Professional | | $3,825.00 | $3,825.00 | $5,814.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,275.00 / $4,275.00 / $20,731.70
| Facility | | $4,275.00 | $4,275.00 | $20,731.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,750.00 / $3,750.00 / $17,100.00
| Professional | | $3,750.00 | $3,750.00 | $17,100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,750.00 / $3,750.00 / $5,625.00
| Professional | | $3,750.00 | $3,750.00 | $5,625.00 |