- 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
- $4,265.80 / $5,128.61 / $6,165.95
| Professional | | $4,265.80 | $5,128.61 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,137.96 / $5,128.61
| Professional | | $1,995.26 | $2,137.96 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,778.28 / $2,187.76
| Professional | | $1,698.24 | $1,778.28 | $2,187.76 |
- 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
- $1,096.48 / $1,445.44 / $1,949.84
| Professional | | $1,096.48 | $1,445.44 | $1,949.84 |