- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,650.46 / $2,510.21 / $5,728.55
| Facility | | $1,650.46 | $2,510.21 | $5,728.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,330.41 / $1,650.46 / $1,757.15
| Professional | | $1,330.41 | $1,650.46 | $1,757.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $760.00 / $1,164.24 / $5,568.90
| Facility | | $760.00 | $1,164.24 | $5,568.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.17 / $935.78 / $1,656.73
| Professional | | $720.17 | $935.78 | $1,656.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,631.64 / $8,073.80 / $14,407.41
| Facility | | $1,631.64 | $8,073.80 | $14,407.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,757.15 / $4,573.60 / $6,200.22
| Professional | | $1,757.15 | $4,573.60 | $6,200.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,154.70 / $1,506.13 / $4,405.17
| Professional | | $1,154.70 | $1,506.13 | $4,405.17 |