- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,245.83 / $1,245.83 / $1,794.75
| Facility | | $1,245.83 | $1,245.83 | $1,794.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $483.20 / $483.20 / $483.20
| Professional | | $483.20 | $483.20 | $483.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $538.42 / $1,435.81 / $2,692.14
| Facility | | $538.42 | $1,435.81 | $2,692.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $830.55 / $1,346.07 / $1,480.68
| Facility | | $830.55 | $1,346.07 | $1,480.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $690.29 / $690.29 / $828.35
| Professional | | $690.29 | $690.29 | $828.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,035.44 / $1,380.58 / $2,485.04
| Facility | | $1,035.44 | $1,380.58 | $2,485.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.81 / $1,031.81 / $1,066.17
| Professional | | $1,031.81 | $1,031.81 | $1,066.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.92 / $289.92 / $793.83
| Professional | | $289.92 | $289.92 | $793.83 |