- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,238.72 / $2,238.72
| Facility | | $1,412.54 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,905.46 / $2,290.87
| Professional | | $1,202.26 | $1,905.46 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Facility | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,332.54 / $9,332.54 / $9,332.54
| Professional | | $9,332.54 | $9,332.54 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $20,417.38
| Facility | | $2,884.03 | $2,884.03 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $1,023.29 / $2,884.03
| Professional | | $562.34 | $1,023.29 | $2,884.03 |