- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $6,760.83 / $14,454.40
| Facility | | $3,090.30 | $6,760.83 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,089.30 / $5,011.87
| Facility | | $1,513.56 | $2,089.30 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,659.59 / $2,398.83
| Professional | | $1,000.00 | $1,659.59 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,128.61 / $12,589.25
| Facility | | $2,951.21 | $5,128.61 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $870.96 / $1,513.56
| Professional | | $602.56 | $870.96 | $1,513.56 |