- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $4,365.16 / $10,964.78
| Facility | | $1,096.48 | $4,365.16 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $870.96 / $2,137.96
| Professional | | $724.44 | $870.96 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $7,079.46 / $14,454.40
| Facility | | $2,398.83 | $7,079.46 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $977.24 / $1,949.84
| Professional | | $724.44 | $977.24 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $2,290.87 / $6,456.54
| Facility | | $977.24 | $2,290.87 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,202.26 / $2,630.27
| Professional | | $776.25 | $1,202.26 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $4,265.80 / $9,772.37
| Facility | | $1,584.89 | $4,265.80 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $977.24 / $1,862.09
| Professional | | $691.83 | $977.24 | $1,862.09 |