- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,052.36 / $4,328.63 / $10,413.11
| Facility | | $3,052.36 | $4,328.63 | $10,413.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,463.60 / $4,009.50 / $5,814.77
| Professional | | $2,463.60 | $4,009.50 | $5,814.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,481.35 / $3,957.41 / $8,199.29
| Facility | | $2,481.35 | $3,957.41 | $8,199.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,058.79 / $3,304.36 / $4,918.85
| Professional | | $2,058.79 | $3,304.36 | $4,918.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,774.63 / $1,957.41 / $3,408.23
| Facility | | $1,774.63 | $1,957.41 | $3,408.23 |
- 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 |