- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,107.73 / $1,107.73 / $1,637.51
| Facility | | $1,107.73 | $1,107.73 | $1,637.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.73 / $1,473.83 / $1,637.51
| Professional | | $1,107.73 | $1,473.83 | $1,637.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,576.95 / $1,651.06 / $2,122.79
| Professional | | $1,576.95 | $1,651.06 | $2,122.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $247.92 / $1,859.42 / $3,552.91
| Facility | | $247.92 | $1,859.42 | $3,552.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.03 / $2,450.28 / $4,042.96
| Professional | | $245.03 | $2,450.28 | $4,042.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,772.06 / $1,772.06 / $2,860.35
| Facility | | $1,772.06 | $1,772.06 | $2,860.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,506.25 / $1,772.06 / $2,348.05
| Professional | | $1,506.25 | $1,772.06 | $2,348.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.60 / $242.16 / $2,421.65
| Professional | | $194.60 | $242.16 | $2,421.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.65 / $1,064.29 / $1,508.42
| Facility | | $120.65 | $1,064.29 | $1,508.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $835.14 / $1,279.48 / $2,004.86
| Professional | | $835.14 | $1,279.48 | $2,004.86 |