- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,619.76 / $8,706.79 / $16,841.75
| Facility | | $6,619.76 | $8,706.79 | $16,841.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $882.91 / $1,504.98 / $2,006.64
| Professional | | $882.91 | $1,504.98 | $2,006.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,411.22 / $2,571.11 / $8,892.70
| Facility | | $1,411.22 | $2,571.11 | $8,892.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,229.79 / $1,844.68 / $2,648.77
| Professional | | $1,229.79 | $1,844.68 | $2,648.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,625.24 / $8,505.44 / $10,626.65
| Facility | | $1,625.24 | $8,505.44 | $10,626.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,625.24 / $1,625.24 / $1,625.24
| Professional | | $1,625.24 | $1,625.24 | $1,625.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,229.79 / $2,098.21 / $2,648.77
| Professional | | $1,229.79 | $2,098.21 | $2,648.77 |