- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $14,791.08 / $15,848.93
| Facility | | $11,748.98 | $14,791.08 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,311.31 / $3,981.07
| Professional | | $2,754.23 | $3,311.31 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,380.38 / $3,311.31
| Professional | | $1,288.25 | $1,380.38 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,230.27 / $1,479.11
| Professional | | $1,174.90 | $1,230.27 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $3,311.31 / $4,365.16
| Facility | | $436.52 | $3,311.31 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $933.25 / $1,318.26
| Professional | | $724.44 | $933.25 | $1,318.26 |