- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $2,290.87 / $3,981.07
| Facility | | $776.25 | $2,290.87 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $512.86 / $1,148.15
| Professional | | $295.12 | $512.86 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,290.87 / $3,019.95
| Facility | | $1,348.96 | $2,290.87 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $588.84 / $1,000.00
| Professional | | $371.54 | $588.84 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Facility | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $524.81 / $912.01
| Professional | | $346.74 | $524.81 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $28,840.32
| Facility | | $3,981.07 | $3,981.07 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,365.16 / $4,365.16
| Professional | | $3,715.35 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,290.87 / $4,073.80
| Facility | | $1,202.26 | $2,290.87 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $478.63 / $831.76
| Professional | | $295.12 | $478.63 | $831.76 |