- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,115.00 / $4,476.96 / $11,576.00
| Facility | | $1,115.00 | $4,476.96 | $11,576.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,575.67 / $1,575.67 / $1,575.67
| Professional | | $1,575.67 | $1,575.67 | $1,575.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.00 / $977.92 / $1,164.19
| Facility | | $323.00 | $977.92 | $1,164.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,297.33 / $1,383.82 / $1,496.26
| Facility | | $1,297.33 | $1,383.82 | $1,496.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,014.00 / $3,611.00 / $8,105.00
| Facility | | $1,014.00 | $3,611.00 | $8,105.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.00 / $16.00 / $16.00
| Professional | | $16.00 | $16.00 | $16.00 |