- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,990.04 / $4,240.24 / $10,200.48
| Facility | | $2,990.04 | $4,240.24 | $10,200.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,413.29 / $3,927.63 / $5,696.04
| Professional | | $2,413.29 | $3,927.63 | $5,696.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,430.69 / $3,876.60 / $8,031.88
| Facility | | $2,430.69 | $3,876.60 | $8,031.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.76 / $3,236.89 / $4,818.42
| Professional | | $2,016.76 | $3,236.89 | $4,818.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,108.09 / $3,108.09 / $3,108.09
| Facility | | $3,108.09 | $3,108.09 | $3,108.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,636.00 / $13,636.00 / $13,636.00
| Professional | | $13,636.00 | $13,636.00 | $13,636.00 |