- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,267.13 / $3,742.00 / $18,600.00
| Facility | | $1,267.13 | $3,742.00 | $18,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,267.13 / $1,267.13 / $1,280.76
| Professional | | $1,267.13 | $1,267.13 | $1,280.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,454.51 / $1,845.23 / $2,227.96
| Professional | | $1,454.51 | $1,845.23 | $2,227.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $773.00 / $1,920.09 / $5,882.00
| Facility | | $773.00 | $1,920.09 | $5,882.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,305.83 / $1,829.75 / $10,240.71
| Professional | | $1,305.83 | $1,829.75 | $10,240.71 |
- 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
- $1,245.81 / $1,651.07 / $2,301.82
| Professional | | $1,245.81 | $1,651.07 | $2,301.82 |