- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $12,589.25 / $21,877.62
| Facility | | $4,570.88 | $12,589.25 | $21,877.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,495.41 / $12,882.50
| Facility | | $3,890.45 | $5,495.41 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,365.16 / $6,309.57
| Professional | | $3,019.95 | $4,365.16 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $2,187.76 / $6,606.93
| Facility | | $891.25 | $2,187.76 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,949.84 / $3,090.30
| Professional | | $1,380.38 | $1,949.84 | $3,090.30 |