- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,659.59 / $2,344.23
| Facility | | $1,096.48 | $1,659.59 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,096.48 / $2,137.96
| Professional | | $912.01 | $1,096.48 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $11,481.54 / $15,848.93
| Facility | | $9,549.93 | $11,481.54 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,412.54 / $1,737.80
| Professional | | $977.24 | $1,412.54 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,737.80
| Facility | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,096.48 / $2,454.71
| Professional | | $851.14 | $1,096.48 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $4,365.16 / $6,918.31
| Facility | | $1,479.11 | $4,365.16 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,023.29 / $1,778.28
| Professional | | $794.33 | $1,023.29 | $1,778.28 |