- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $11,220.18 / $18,620.87
| Facility | | $5,011.87 | $11,220.18 | $18,620.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,570.88 / $11,220.18
| Facility | | $3,311.31 | $4,570.88 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,715.35 / $5,495.41
| Professional | | $2,570.40 | $3,715.35 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $2,187.76 / $6,606.93
| Facility | | $891.25 | $2,187.76 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,479.11 / $2,454.71
| Professional | | $1,096.48 | $1,479.11 | $2,454.71 |