- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,200.52 / $1,200.52 / $1,200.52
| Facility | | $1,200.52 | $1,200.52 | $1,200.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.16 / $1,278.44 / $1,951.72
| Professional | | $1,094.16 | $1,278.44 | $1,951.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,787.17 / $1,787.17 / $3,266.85
| Facility | | $1,787.17 | $1,787.17 | $3,266.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.63 / $1,304.63 / $3,724.50
| Professional | | $1,304.63 | $1,304.63 | $3,724.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,984.51 / $3,005.50 / $4,279.57
| Professional | | $2,984.51 | $3,005.50 | $4,279.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,190.28 / $3,266.85 / $3,266.85
| Professional | | $3,190.28 | $3,266.85 | $3,266.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,448.21 / $1,448.21 / $1,448.21
| Facility | | $1,448.21 | $1,448.21 | $1,448.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,408.10 / $1,629.79 / $3,266.85
| Professional | | $1,408.10 | $1,629.79 | $3,266.85 |