- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,715.35 / $9,549.93
| Facility | | $1,148.15 | $3,715.35 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,096.48 / $2,089.30
| Professional | | $933.25 | $1,096.48 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $5,248.07 / $10,964.78
| Facility | | $2,089.30 | $5,248.07 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,122.02 / $2,137.96
| Professional | | $851.14 | $1,122.02 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,737.80 / $4,073.80
| Facility | | $588.84 | $1,737.80 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,348.96 / $2,818.38
| Professional | | $851.14 | $1,348.96 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,981.07 / $9,549.93
| Facility | | $1,047.13 | $3,981.07 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,174.90 / $2,137.96
| Professional | | $831.76 | $1,174.90 | $2,137.96 |