- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $6,456.54 / $8,709.64
| Facility | | $1,096.48 | $6,456.54 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $1,096.48 / $2,089.30
| Professional | | $512.86 | $1,096.48 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $3,162.28 / $5,370.32
| Professional | | $812.83 | $3,162.28 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,096.48 / $2,089.30
| Facility | | $794.33 | $1,096.48 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $7,244.36 / $10,471.29
| Facility | | $2,398.83 | $7,244.36 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,454.71 / $3,890.45
| Professional | | $1,621.81 | $2,454.71 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $7,079.46
| Facility | | $7,079.46 | $7,079.46 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $7,079.46
| Professional | | $7,079.46 | $7,079.46 | $7,079.46 |