- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,398.83 / $2,630.27
| Facility | | $1,318.26 | $2,398.83 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,047.13 / $2,398.83
| Professional | | $831.76 | $1,047.13 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,148.15
| Facility | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,148.15
| Professional | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $891.25
| Facility | | $851.14 | $851.14 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $39.81
| Professional | | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,348.96
| Facility | | $1,000.00 | $1,000.00 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $676.08 / $2,511.89
| Professional | | $467.74 | $676.08 | $2,511.89 |