- 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
- $1,584.89 / $2,238.72 / $2,951.21
| Professional | | $1,584.89 | $2,238.72 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,691.53 / $3,715.35
| Facility | | $1,778.28 | $2,691.53 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $2,454.71 / $2,951.21
| Professional | | $977.24 | $2,454.71 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $7,943.28 / $10,471.29
| Professional | | $2,691.53 | $7,943.28 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,454.71 / $3,715.35
| Facility | | $1,778.28 | $2,454.71 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $6,606.93 / $8,511.38
| Professional | | $549.54 | $6,606.93 | $8,511.38 |