- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $12,022.64 / $16,595.87
| Facility | | $9,772.37 | $12,022.64 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $1,862.09
| Professional | | $1,096.48 | $1,445.44 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $1,445.44 / $2,041.74
| Facility | | $707.95 | $1,445.44 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,445.44 / $2,454.71
| Professional | | $707.95 | $1,445.44 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,677.35 / $6,606.93
| Professional | | $4,365.16 | $4,677.35 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,949.84 / $2,041.74
| Facility | | $1,445.44 | $1,949.84 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,344.23 / $5,370.32
| Professional | | $1,479.11 | $2,344.23 | $5,370.32 |