- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.62 / $2,041.62 / $13,831.70
| Facility | | $2,041.62 | $2,041.62 | $13,831.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.62 / $2,041.62 / $2,041.62
| Professional | | $2,041.62 | $2,041.62 | $2,041.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,916.60 / $2,916.60 / $3,988.45
| Professional | | $2,916.60 | $2,916.60 | $3,988.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,300.63 / $7,185.04 / $16,629.87
| Facility | | $5,300.63 | $7,185.04 | $16,629.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,274.94 / $2,916.60 / $3,674.92
| Facility | | $2,274.94 | $2,916.60 | $3,674.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.97 / $1,604.13 / $2,655.89
| Professional | | $1,224.97 | $1,604.13 | $2,655.89 |