- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $13,803.84 / $28,840.32
| Facility | | $5,011.87 | $13,803.84 | $28,840.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,884.03 / $6,918.31
| Facility | | $2,041.74 | $2,884.03 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,290.87 / $3,715.35
| Professional | | $1,513.56 | $2,290.87 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $1,905.46 / $6,309.57
| Facility | | $602.56 | $1,905.46 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $954.99 / $1,479.11
| Professional | | $691.83 | $954.99 | $1,479.11 |