- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,360.71 / $1,360.71 / $1,486.71
| Facility | | $1,360.71 | $1,360.71 | $1,486.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,335.52 / $1,431.90 / $2,546.85
| Professional | | $1,335.52 | $1,431.90 | $2,546.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,802.02 / $2,722.05 / $2,722.05
| Professional | | $1,802.02 | $2,722.05 | $2,722.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,572.92 / $1,815.81 / $1,815.81
| Facility | | $1,572.92 | $1,815.81 | $1,815.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,325.54 / $1,325.54 / $1,815.81
| Professional | | $1,325.54 | $1,325.54 | $1,815.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,851.93 / $15,138.02 / $18,404.34
| Facility | | $4,851.93 | $15,138.02 | $18,404.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18,962.96 / $19,418.09 / $22,132.73
| Professional | | $18,962.96 | $19,418.09 | $22,132.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,005.92 / $1,508.89 / $2,183.83
| Professional | | $1,005.92 | $1,508.89 | $2,183.83 |