- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,355.94 / $2,355.94 / $3,393.96
| Facility | | $2,355.94 | $2,355.94 | $3,393.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $913.76 / $1,227.05 / $1,227.05
| Professional | | $913.76 | $1,227.05 | $1,227.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,018.19 / $2,715.17 / $5,090.93
| Facility | | $1,018.19 | $2,715.17 | $5,090.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,570.62 / $2,545.46 / $2,800.02
| Facility | | $1,570.62 | $2,545.46 | $2,800.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,305.36 / $1,331.48 / $1,566.44
| Professional | | $1,305.36 | $1,331.48 | $1,566.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $1,305.36
| Professional | | $30.00 | $30.00 | $1,305.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,958.06 / $2,610.73 / $4,699.33
| Facility | | $1,958.06 | $2,610.73 | $4,699.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,951.20 / $1,951.20 / $2,016.14
| Professional | | $1,951.20 | $1,951.20 | $2,016.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $548.26 / $548.26 / $1,566.44
| Professional | | $548.26 | $548.26 | $1,566.44 |