- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,184.76 / $1,257.66 / $1,786.25
| Facility | | $1,184.76 | $1,257.66 | $1,786.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $962.18 / $1,257.66 / $1,822.70
| Professional | | $962.18 | $1,257.66 | $1,822.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,908.00 / $3,259.53 / $4,581.72
| Facility | | $1,908.00 | $3,259.53 | $4,581.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,301.19 / $1,556.41 / $1,556.41
| Professional | | $1,301.19 | $1,556.41 | $1,556.41 |
- 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
- $1,573.58 / $1,573.58 / $1,573.58
| Facility | | $1,573.58 | $1,573.58 | $1,573.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.71 / $1,573.58 / $1,573.58
| Professional | | $1,148.71 | $1,573.58 | $1,573.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,261.08 / $1,261.08 / $1,261.08
| Facility | | $1,261.08 | $1,261.08 | $1,261.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $606.78 / $1,093.61 / $1,443.52
| Professional | | $606.78 | $1,093.61 | $1,443.52 |