- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,071.52 / $2,041.74
| Facility | | $676.08 | $1,071.52 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $851.14 / $1,122.02
| Professional | | $630.96 | $851.14 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,949.84
| Facility | | $1,412.54 | $1,412.54 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,000.00 / $1,318.26
| Professional | | $831.76 | $1,000.00 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,737.80
| Facility | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $977.24 / $1,445.44
| Professional | | $416.87 | $977.24 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,445.44 / $4,365.16
| Facility | | $588.84 | $1,445.44 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $812.83 / $1,445.44
| Professional | | $562.34 | $812.83 | $1,445.44 |