- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $5,248.07
| Facility | | $1,288.25 | $1,288.25 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,288.25 / $1,548.82
| Professional | | $1,148.15 | $1,288.25 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $1,047.13 / $1,230.27
| Professional | | $436.52 | $1,047.13 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $812.83
| Facility | | $741.31 | $741.31 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,288.25 / $1,288.25
| Facility | | $1,000.00 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Professional | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.20 / $489.78 / $1,202.26
| Facility | | $1.20 | $489.78 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $1,288.25 / $1,949.84
| Professional | | $512.86 | $1,288.25 | $1,949.84 |