- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,841.80 / $4,030.02 / $9,694.77
| Facility | | $2,841.80 | $4,030.02 | $9,694.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,293.65 / $3,732.91 / $5,413.64
| Professional | | $2,293.65 | $3,732.91 | $5,413.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,310.17 / $3,684.41 / $7,633.68
| Facility | | $2,310.17 | $3,684.41 | $7,633.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,916.77 / $3,076.41 / $4,579.53
| Professional | | $1,916.77 | $3,076.41 | $4,579.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,860.86 / $1,964.56 / $3,524.95
| Facility | | $1,860.86 | $1,964.56 | $3,524.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,682.00 / $15,682.00 / $15,682.00
| Professional | | $15,682.00 | $15,682.00 | $15,682.00 |