- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $8,511.38
| Facility | | $5,011.87 | $5,011.87 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,019.95 / $6,606.93
| Professional | | $1,479.11 | $3,019.95 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,818.38 / $3,981.07
| Professional | | $1,905.46 | $2,818.38 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,311.31 / $11,220.18
| Facility | | $2,818.38 | $3,311.31 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $17,378.01
| Professional | | $1,513.56 | $1,513.56 | $17,378.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $5,370.32 / $11,748.98
| Facility | | $2,691.53 | $5,370.32 | $11,748.98 |