- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,300.00 / $3,842.75 / $18,600.00
| Facility | | $1,300.00 | $3,842.75 | $18,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,175.37 / $3,842.75 / $4,250.74
| Professional | | $3,175.37 | $3,842.75 | $4,250.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,723.87 / $4,132.00 / $5,893.86
| Facility | | $1,723.87 | $4,132.00 | $5,893.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,189.71 / $4,281.66 / $25,728.72
| Professional | | $3,189.71 | $4,281.66 | $25,728.72 |
- 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
- $3,002.08 / $3,805.92 / $5,971.14
| Professional | | $3,002.08 | $3,805.92 | $5,971.14 |