- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $970.92 / $1,030.67 / $1,463.86
| Facility | | $970.92 | $1,030.67 | $1,463.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $841.08 / $1,030.67 / $1,493.73
| Professional | | $841.08 | $1,030.67 | $1,493.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,563.64 / $2,671.24 / $3,754.79
| Facility | | $1,563.64 | $2,671.24 | $3,754.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.34 / $1,275.49 / $1,275.49
| Professional | | $1,066.34 | $1,275.49 | $1,275.49 |
- 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
- $1,020.64 / $1,020.64 / $1,020.64
| Facility | | $1,020.64 | $1,020.64 | $1,020.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $745.07 / $1,020.64 / $1,020.64
| Professional | | $745.07 | $1,020.64 | $1,020.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.40 / $913.58 / $1,291.20
| Professional | | $530.40 | $913.58 | $1,291.20 |