- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,350.70 / $1,350.70 / $1,945.81
| Facility | | $1,350.70 | $1,350.70 | $1,945.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $523.87 / $523.87 / $523.87
| Professional | | $523.87 | $523.87 | $523.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $583.74 / $1,556.64 / $2,918.70
| Facility | | $583.74 | $1,556.64 | $2,918.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $900.47 / $1,459.36 / $1,605.30
| Facility | | $900.47 | $1,459.36 | $1,605.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.39 / $748.39 / $898.07
| Professional | | $748.39 | $748.39 | $898.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $748.39
| Professional | | $30.00 | $30.00 | $748.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.58 / $1,496.78 / $2,694.20
| Facility | | $1,122.58 | $1,496.78 | $2,694.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,118.38 / $1,118.38 / $1,155.67
| Professional | | $1,118.38 | $1,118.38 | $1,155.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.32 / $314.32 / $860.65
| Professional | | $314.32 | $314.32 | $860.65 |