- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,282.68 / $1,282.68 / $2,000.98
| Facility | | $1,282.68 | $1,282.68 | $2,000.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.16 / $1,282.68 / $1,282.68
| Professional | | $1,107.16 | $1,282.68 | $1,282.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,055.58 / $1,513.49 / $2,682.38
| Facility | | $1,055.58 | $1,513.49 | $2,682.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $962.01 / $1,012.64 / $1,083.52
| Professional | | $962.01 | $1,012.64 | $1,083.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $540.08 / $1,350.19 / $1,939.55
| Professional | | $540.08 | $1,350.19 | $1,939.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,270.26 / $1,282.68 / $2,356.92
| Facility | | $1,270.26 | $1,282.68 | $2,356.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,270.26 / $1,282.68 / $1,620.23
| Professional | | $1,270.26 | $1,282.68 | $1,620.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $567.08 / $810.11 / $1,350.19
| Professional | | $567.08 | $810.11 | $1,350.19 |