- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,008.02 / $1,391.83 / $3,109.00
| Facility | | $1,008.02 | $1,391.83 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $738.55 / $1,034.04 / $1,078.26
| Professional | | $738.55 | $1,034.04 | $1,078.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $783.86 / $1,037.47 / $1,037.47
| Professional | | $783.86 | $1,037.47 | $1,037.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $946.18 / $1,269.93 / $1,637.48
| Professional | | $946.18 | $1,269.93 | $1,637.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $1,056.00 / $2,558.00
| Facility | | $375.00 | $1,056.00 | $2,558.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $712.33 / $940.81 / $1,490.67
| Professional | | $712.33 | $940.81 | $1,490.67 |