- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,271.70 / $2,056.66 / $4,151.40
| Facility | | $1,271.70 | $2,056.66 | $4,151.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,041.16 / $1,204.77 / $1,487.37
| Professional | | $1,041.16 | $1,204.77 | $1,487.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,175.02 / $1,487.37 / $4,801.97
| Facility | | $1,175.02 | $1,487.37 | $4,801.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.84 / $594.95 / $1,091.72
| Professional | | $329.84 | $594.95 | $1,091.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $966.79 / $2,033.42 / $4,103.53
| Facility | | $966.79 | $2,033.42 | $4,103.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.11 / $1,708.99 / $2,136.23
| Professional | | $870.11 | $1,708.99 | $2,136.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,487.37 / $1,487.37 / $1,859.21
| Facility | | $1,487.37 | $1,487.37 | $1,859.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $624.70 / $892.42 / $1,784.84
| Professional | | $624.70 | $892.42 | $1,784.84 |