- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,200.00 / $3,779.00 / $12,600.00
| Facility | | $1,200.00 | $3,779.00 | $12,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,941.81 / $1,941.81 / $1,941.81
| Professional | | $1,941.81 | $1,941.81 | $1,941.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,733.07 / $7,635.00 / $22,596.00
| Facility | | $1,733.07 | $7,635.00 | $22,596.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,014.89 / $1,549.04 / $27,827.90
| Professional | | $1,014.89 | $1,549.04 | $27,827.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,960.00 / $9,469.00 / $20,190.00
| Facility | | $1,960.00 | $9,469.00 | $20,190.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,039.06 / $1,408.22 / $2,586.90
| Professional | | $1,039.06 | $1,408.22 | $2,586.90 |