- 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
- $2,238.72 / $3,090.30 / $7,585.78
| Facility | | $2,238.72 | $3,090.30 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,511.89 / $4,073.80
| Professional | | $1,621.81 | $2,511.89 | $4,073.80 |
- 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
- $724.44 / $1,000.00 / $1,584.89
| Professional | | $724.44 | $1,000.00 | $1,584.89 |