- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $10,471.29 / $20,892.96
| Facility | | $3,630.78 | $10,471.29 | $20,892.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,630.27 / $6,309.57
| Facility | | $1,862.09 | $2,630.27 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,089.30 / $3,388.44
| Professional | | $1,380.38 | $2,089.30 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $1,862.09 / $6,309.57
| Facility | | $602.56 | $1,862.09 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $831.76 / $1,318.26
| Professional | | $616.60 | $831.76 | $1,318.26 |