- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,445.44 / $2,238.72
| Facility | | $758.58 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,230.27 / $1,905.46
| Professional | | $954.99 | $1,230.27 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $11,220.18 / $15,488.17
| Facility | | $9,549.93 | $11,220.18 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,202.26 / $1,548.82
| Professional | | $831.76 | $1,202.26 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,148.15 / $1,905.46
| Professional | | $758.58 | $1,148.15 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,884.03 / $4,073.80
| Facility | | $831.76 | $2,884.03 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,023.29 / $1,659.59
| Professional | | $758.58 | $1,023.29 | $1,659.59 |