- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,162.28 / $4,265.80
| Facility | | $1,737.80 | $3,162.28 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,318.26 / $1,445.44
| Professional | | $741.31 | $1,318.26 | $1,445.44 |
- 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 / $1,122.02 / $1,202.26
| Facility | | $851.14 | $1,122.02 | $1,202.26 |
- 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 / $1,737.80
| Facility | | $1,000.00 | $1,000.00 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $676.08 / $2,511.89
| Professional | | $467.74 | $676.08 | $2,511.89 |