- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,290.87 / $4,073.80
| Facility | | $758.58 | $2,290.87 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,202.26 / $2,398.83
| Professional | | $1,023.29 | $1,202.26 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,951.21 / $3,981.07
| Facility | | $1,584.89 | $2,951.21 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,778.28 / $2,691.53
| Professional | | $1,258.93 | $1,778.28 | $2,691.53 |
- 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
- $1,096.48 / $1,479.11 / $2,511.89
| Professional | | $1,096.48 | $1,479.11 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $28,840.32
| Facility | | $7,244.36 | $7,244.36 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,511.38 / $10,000.00 / $10,000.00
| Professional | | $8,511.38 | $10,000.00 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,570.88 / $7,585.78
| Facility | | $2,754.23 | $4,570.88 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,380.38 / $2,344.23
| Professional | | $977.24 | $1,380.38 | $2,344.23 |