- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,807.27 / $3,981.05 / $9,576.95
| Facility | | $2,807.27 | $3,981.05 | $9,576.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,265.77 / $3,687.55 / $5,347.86
| Professional | | $2,265.77 | $3,687.55 | $5,347.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,282.11 / $3,639.64 / $7,540.91
| Facility | | $2,282.11 | $3,639.64 | $7,540.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,893.48 / $3,039.03 / $4,523.88
| Professional | | $1,893.48 | $3,039.03 | $4,523.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,045.23 / $3,045.23 / $3,045.23
| Facility | | $3,045.23 | $3,045.23 | $3,045.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,233.00 / $14,233.00 / $14,233.00
| Professional | | $14,233.00 | $14,233.00 | $14,233.00 |