- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,778.28 / $2,290.87
| Facility | | $1,412.54 | $1,778.28 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,778.28 / $2,951.21
| Professional | | $1,380.38 | $1,778.28 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $6,456.54
| Facility | | $6,456.54 | $6,456.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,982.44 / $16,982.44 / $16,982.44
| Professional | | $16,982.44 | $16,982.44 | $16,982.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $29,512.09
| Facility | | $4,466.84 | $4,466.84 | $29,512.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,344.23 / $3,548.13
| Professional | | $1,479.11 | $2,344.23 | $3,548.13 |