- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,296.46 / $1,321.88 / $1,321.88
| Facility | | $1,296.46 | $1,321.88 | $1,321.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,014.50 / $1,321.88 / $2,270.96
| Professional | | $1,014.50 | $1,321.88 | $2,270.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,817.93 / $2,746.07 / $2,746.07
| Professional | | $1,817.93 | $2,746.07 | $2,746.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,223.23 / $1,665.63 / $1,665.63
| Facility | | $1,223.23 | $1,665.63 | $1,665.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,215.91 / $1,215.91 / $1,665.63
| Professional | | $1,215.91 | $1,215.91 | $1,665.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,119.10 / $12,133.56 / $12,133.56
| Facility | | $4,119.10 | $12,133.56 | $12,133.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,645.71 / $14,645.71 / $22,883.93
| Professional | | $14,645.71 | $14,645.71 | $22,883.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $951.38 / $1,490.44 / $1,787.81
| Professional | | $951.38 | $1,490.44 | $1,787.81 |