- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $758.58 / $2,041.74
| Facility | | $562.34 | $758.58 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $724.44 / $1,148.15
| Professional | | $575.44 | $724.44 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $147.91 / $1,548.82
| Facility | | $109.65 | $147.91 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,096.48 / $1,862.09
| Professional | | $691.83 | $1,096.48 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $5,623.41
| Facility | | $812.83 | $812.83 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $1,995.26
| Professional | | $691.83 | $691.83 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,000.00 / $1,778.28
| Facility | | $645.65 | $1,000.00 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $691.83 / $1,096.48
| Professional | | $537.03 | $691.83 | $1,096.48 |