- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $886.25 / $987.53 / $6,004.18
| Facility | | $886.25 | $987.53 | $6,004.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $850.00 / $987.53 / $1,012.86
| Professional | | $850.00 | $987.53 | $1,012.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,266.07 / $1,266.07 / $1,731.35
| Professional | | $1,266.07 | $1,266.07 | $1,731.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $843.65 / $2,567.60 / $7,218.92
| Facility | | $843.65 | $2,567.60 | $7,218.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $974.87 / $1,266.07 / $1,354.69
| Facility | | $974.87 | $1,266.07 | $1,354.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $531.75 / $696.34 / $1,152.90
| Professional | | $531.75 | $696.34 | $1,152.90 |