- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $11,220.18 / $19,054.61
| Facility | | $5,011.87 | $11,220.18 | $19,054.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $3,162.28 / $12,882.50
| Facility | | $1,445.44 | $3,162.28 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $1,445.44
| Professional | | $1,445.44 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,073.80 / $4,897.79
| Professional | | $3,388.44 | $4,073.80 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,122.02 / $1,737.80
| Professional | | $870.96 | $1,122.02 | $1,737.80 |