- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,020.58 / $1,059.02 / $1,384.53
| Facility | | $1,020.58 | $1,059.02 | $1,384.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.84 / $1,059.02 / $1,293.48
| Professional | | $868.84 | $1,059.02 | $1,293.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $911.06 / $1,205.82 / $1,205.82
| Professional | | $911.06 | $1,205.82 | $1,205.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $900.00 / $1,350.27 / $1,775.00
| Professional | | $900.00 | $1,350.27 | $1,775.00 |
- 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
- $824.31 / $1,024.09 / $1,725.51
| Professional | | $824.31 | $1,024.09 | $1,725.51 |