- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,589.37 / $1,589.37 / $1,736.54
| Facility | | $1,589.37 | $1,589.37 | $1,736.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,559.94 / $1,677.67 / $2,974.84
| Professional | | $1,559.94 | $1,677.67 | $2,974.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,104.84 / $3,179.47 / $3,179.47
| Professional | | $2,104.84 | $3,179.47 | $3,179.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,888.38 / $2,507.59 / $2,507.59
| Facility | | $1,888.38 | $2,507.59 | $2,507.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,830.54 / $1,830.54 / $2,507.59
| Professional | | $1,830.54 | $1,830.54 | $2,507.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,931.26 / $18,505.52 / $22,374.02
| Facility | | $5,931.26 | $18,505.52 | $22,374.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,060.61 / $28,734.08 / $28,734.08
| Professional | | $28,060.61 | $28,734.08 | $28,734.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.96 / $1,725.67 / $2,528.44
| Professional | | $1,174.96 | $1,725.67 | $2,528.44 |