- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $955.74 / $1,397.00 / $4,478.00
| Facility | | $955.74 | $1,397.00 | $4,478.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $734.91 / $1,030.27 / $1,127.21
| Professional | | $734.91 | $1,030.27 | $1,127.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $770.39 / $1,019.63 / $1,019.63
| Professional | | $770.39 | $1,019.63 | $1,019.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $929.62 / $1,161.74 / $1,432.47
| Professional | | $929.62 | $1,161.74 | $1,432.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $980.00 / $1,650.00 / $4,233.00
| Facility | | $980.00 | $1,650.00 | $4,233.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $685.19 / $1,024.25 / $1,467.07
| Professional | | $685.19 | $1,024.25 | $1,467.07 |