- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,412.54 / $1,621.81
| Facility | | $812.83 | $1,412.54 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $707.95 / $1,047.13
| Professional | | $562.34 | $707.95 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $616.60 / $1,348.96
| Professional | | $338.84 | $616.60 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,621.81 / $1,995.26
| Facility | | $1,096.48 | $1,621.81 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $977.24 / $1,202.26
| Professional | | $954.99 | $977.24 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,479.11 / $3,981.07
| Facility | | $724.44 | $1,479.11 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $501.19 / $912.01
| Professional | | $354.81 | $501.19 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $831.76 / $1,000.00
| Facility | | $354.81 | $831.76 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $501.19 / $1,000.00
| Professional | | $354.81 | $501.19 | $1,000.00 |