- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,776.84 / $2,769.78 / $7,780.50
| Facility | | $1,776.84 | $2,769.78 | $7,780.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,167.08 / $1,456.65 / $1,491.75
| Professional | | $1,167.08 | $1,456.65 | $1,491.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $571.33 / $2,169.73 / $3,437.17
| Facility | | $571.33 | $2,169.73 | $3,437.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $543.95 / $791.20 / $3,832.38
| Professional | | $543.95 | $791.20 | $3,832.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,172.32 / $2,851.88 / $5,133.38
| Facility | | $1,172.32 | $2,851.88 | $5,133.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,306.50 / $1,950.00 / $3,393.00
| Facility | | $1,306.50 | $1,950.00 | $3,393.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.10 / $737.10 / $9,711.00
| Professional | | $737.10 | $737.10 | $9,711.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.10 / $737.10 / $1,053.00
| Professional | | $737.10 | $737.10 | $1,053.00 |