- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,552.81 / $3,073.50 / $4,749.17
| Facility | | $1,552.81 | $3,073.50 | $4,749.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.53 / $1,294.01 / $1,591.49
| Professional | | $1,115.53 | $1,294.01 | $1,591.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.61 / $224.61 / $224.61
| Professional | | $224.61 | $224.61 | $224.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $187.22 / $1,343.84 / $3,011.55
| Facility | | $187.22 | $1,343.84 | $3,011.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,212.74 / $2,136.23 / $2,170.42
| Professional | | $1,212.74 | $2,136.23 | $2,170.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $743.69 / $743.69 / $2,588.02
| Facility | | $743.69 | $743.69 | $2,588.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $624.70 / $892.42 / $2,528.53
| Professional | | $624.70 | $892.42 | $2,528.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,090.27 / $4,090.27 / $4,090.27
| Facility | | $4,090.27 | $4,090.27 | $4,090.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $624.70 / $892.42 / $2,528.53
| Professional | | $624.70 | $892.42 | $2,528.53 |