- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,196.69 / $1,398.42 / $2,255.61
| Facility | | $1,196.69 | $1,398.42 | $2,255.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.77 / $1,650.76 / $1,875.86
| Professional | | $902.77 | $1,650.76 | $1,875.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,414.80 / $5,414.80 / $5,414.80
| Facility | | $5,414.80 | $5,414.80 | $5,414.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,058.35 / $2,058.35 / $2,058.35
| Professional | | $2,058.35 | $2,058.35 | $2,058.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $58.40 / $70.00
| Professional | | $50.00 | $58.40 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,414.80 / $5,414.80 / $5,414.80
| Facility | | $5,414.80 | $5,414.80 | $5,414.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,431.94 / $2,058.35 / $2,058.35
| Professional | | $1,431.94 | $2,058.35 | $2,058.35 |