- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,490.66 / $1,582.39 / $2,247.44
| Facility | | $1,490.66 | $1,582.39 | $2,247.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,254.46 / $1,582.39 / $2,293.32
| Professional | | $1,254.46 | $1,582.39 | $2,293.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,400.65 / $4,101.14 / $5,764.72
| Facility | | $2,400.65 | $4,101.14 | $5,764.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,637.15 / $1,958.26 / $1,958.26
| Professional | | $1,637.15 | $1,958.26 | $1,958.26 |
- 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
- $1,486.28 / $1,486.28 / $1,486.28
| Facility | | $1,486.28 | $1,486.28 | $1,486.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,084.98 / $1,486.28 / $1,486.28
| Professional | | $1,084.98 | $1,486.28 | $1,486.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,428.89 / $1,428.89 / $1,428.89
| Facility | | $1,428.89 | $1,428.89 | $1,428.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $791.10 / $1,402.62 / $1,828.59
| Professional | | $791.10 | $1,402.62 | $1,828.59 |