- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $818.76 / $1,150.00 / $2,223.44
| Facility | | $818.76 | $1,150.00 | $2,223.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $827.03 / $1,035.85 / $1,554.82
| Professional | | $827.03 | $1,035.85 | $1,554.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,531.00 / $1,531.00 / $1,531.00
| Professional | | $1,531.00 | $1,531.00 | $1,531.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $782.26 / $782.26 / $1,485.56
| Facility | | $782.26 | $782.26 | $1,485.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $811.73 / $1,282.33 / $1,740.31
| Professional | | $811.73 | $1,282.33 | $1,740.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $733.37
| Professional | | $32.34 | $32.34 | $733.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $797.58 / $1,103.90 / $1,578.04
| Professional | | $797.58 | $1,103.90 | $1,578.04 |