- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,344.37 / $3,684.00 / $18,600.00
| Facility | | $1,344.37 | $3,684.00 | $18,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,344.37 / $1,344.37 / $1,358.82
| Professional | | $1,344.37 | $1,344.37 | $1,358.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,542.59 / $1,952.78 / $2,361.62
| Professional | | $1,542.59 | $1,952.78 | $2,361.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $773.00 / $1,964.41 / $5,882.00
| Facility | | $773.00 | $1,964.41 | $5,882.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,383.40 / $1,940.44 / $13,781.76
| Professional | | $1,383.40 | $1,940.44 | $13,781.76 |
- 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
- $1,279.09 / $1,743.91 / $2,440.21
| Professional | | $1,279.09 | $1,743.91 | $2,440.21 |