- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,246.56 / $1,323.28 / $1,879.43
| Facility | | $1,246.56 | $1,323.28 | $1,879.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,081.77 / $1,323.28 / $1,917.79
| Professional | | $1,081.77 | $1,323.28 | $1,917.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,007.54 / $3,429.58 / $4,820.75
| Facility | | $2,007.54 | $3,429.58 | $4,820.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,369.07 / $1,637.60 / $1,637.60
| Professional | | $1,369.07 | $1,637.60 | $1,637.60 |
- 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
- $1,637.27 / $1,637.27 / $1,637.27
| Facility | | $1,637.27 | $1,637.27 | $1,637.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.21 / $1,637.27 / $1,637.27
| Professional | | $1,195.21 | $1,637.27 | $1,637.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,366.91 / $1,366.91 / $1,366.91
| Facility | | $1,366.91 | $1,366.91 | $1,366.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $682.19 / $1,150.67 / $1,576.86
| Professional | | $682.19 | $1,150.67 | $1,576.86 |