- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $1,318.26 / $1,380.38
| Facility | | $562.34 | $1,318.26 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $602.56 / $1,071.52
| Professional | | $524.81 | $602.56 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $645.65 / $2,884.03
| Professional | | $588.84 | $645.65 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,513.56 / $3,090.30
| Professional | | $691.83 | $1,513.56 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $758.58 / $1,412.54
| Professional | | $707.95 | $758.58 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,819.70 / $2,089.30
| Facility | | $1,548.82 | $1,819.70 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $1,000.00 / $1,659.59
| Professional | | $457.09 | $1,000.00 | $1,659.59 |