- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,300.00 / $3,816.16 / $18,600.00
| Facility | | $1,300.00 | $3,816.16 | $18,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,229.43 / $3,816.16 / $4,194.16
| Professional | | $3,229.43 | $3,816.16 | $4,194.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,841.57 / $4,415.46 / $5,594.20
| Professional | | $2,841.57 | $4,415.46 | $5,594.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,723.87 / $4,073.00 / $5,882.00
| Facility | | $1,723.87 | $4,073.00 | $5,882.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,161.48 / $4,259.10 / $25,516.11
| Professional | | $3,161.48 | $4,259.10 | $25,516.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $350.00 / $1,760.00 / $6,155.68
| Facility | | $350.00 | $1,760.00 | $6,155.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,975.51 / $3,905.36 / $5,918.29
| Professional | | $2,975.51 | $3,905.36 | $5,918.29 |