- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,406.68 / $1,493.25 / $2,011.55
| Facility | | $1,406.68 | $1,493.25 | $2,011.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,221.75 / $1,493.25 / $1,623.10
| Professional | | $1,221.75 | $1,493.25 | $1,623.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,265.41 / $3,870.11 / $5,439.97
| Facility | | $2,265.41 | $3,870.11 | $5,439.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,544.93 / $1,847.95 / $1,847.95
| Professional | | $1,544.93 | $1,847.95 | $1,847.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $40.00
| Facility | | $40.00 | $40.00 | $40.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,638.80 / $1,638.80 / $1,638.80
| Facility | | $1,638.80 | $1,638.80 | $1,638.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,196.32 / $1,196.32 / $2,937.00
| Professional | | $1,196.32 | $1,196.32 | $2,937.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.94 / $1,203.23 / $1,416.40
| Facility | | $1.94 | $1,203.23 | $1,416.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $809.37 / $1,214.06 / $1,870.83
| Professional | | $809.37 | $1,214.06 | $1,870.83 |