- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,017.00 / $1,702.62 / $7,727.00
| Facility | | $1,017.00 | $1,702.62 | $7,727.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,702.62 / $1,702.62 / $1,702.62
| Professional | | $1,702.62 | $1,702.62 | $1,702.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,628.26 / $1,674.54 / $1,780.00
| Professional | | $1,628.26 | $1,674.54 | $1,780.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,441.82 / $2,040.84 / $3,672.06
| Professional | | $1,441.82 | $2,040.84 | $3,672.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,476.64 / $3,241.75 / $3,241.75
| Professional | | $1,476.64 | $3,241.75 | $3,241.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.00 / $1,319.00 / $16,382.00
| Facility | | $645.00 | $1,319.00 | $16,382.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,250.75 / $2,143.25 / $3,862.43
| Professional | | $1,250.75 | $2,143.25 | $3,862.43 |