- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $4,570.88 / $7,413.10
| Facility | | $1,862.09 | $4,570.88 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,884.03 / $6,918.31
| Facility | | $1,000.00 | $2,884.03 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $831.76 / $5,248.07
| Facility | | $512.86 | $831.76 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $338.84 / $1,096.48
| Professional | | $257.04 | $338.84 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- 52
- Low / Median / High Price
- $229.09 / $229.09 / $288.40
| Professional | 52 | $229.09 | $229.09 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $2,454.71 / $5,248.07
| Facility | | $524.81 | $2,454.71 | $5,248.07 |