- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $1,412.54 / $2,398.83
| Facility | | $575.44 | $1,412.54 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $380.19 / $1,000.00
| Professional | | $281.84 | $380.19 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $331.13 / $602.56
| Professional | | $263.03 | $331.13 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,570.40 / $3,467.37
| Facility | | $2,137.96 | $2,570.40 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $478.63 / $524.81
| Professional | | $338.84 | $478.63 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $380.19 / $575.44
| Professional | | $223.87 | $380.19 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,951.21 / $4,365.16
| Facility | | $831.76 | $2,951.21 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $323.59 / $489.78
| Professional | | $229.09 | $323.59 | $489.78 |