- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,888.44 / $12,302.69
| Facility | | $3,311.31 | $5,888.44 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $4,265.80 / $16,595.87
| Facility | | $1,318.26 | $4,265.80 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,318.26
| Professional | | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,630.78 / $4,365.16
| Professional | | $3,019.95 | $3,630.78 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,000.00 / $1,548.82
| Professional | | $794.33 | $1,000.00 | $1,548.82 |