- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,548.82 / $3,981.07
| Facility | | $1,513.56 | $1,548.82 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $691.83 / $1,778.28
| Professional | | $549.54 | $691.83 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $588.84 / $1,000.00
| Professional | | $436.52 | $588.84 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $741.31 / $1,202.26
| Professional | | $208.93 | $741.31 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,511.89 / $6,025.60
| Facility | | $1,380.38 | $2,511.89 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $776.25 / $1,096.48
| Professional | | $512.86 | $776.25 | $1,096.48 |