- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $10,715.19 / $17,782.79
| Facility | | $4,897.79 | $10,715.19 | $17,782.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,570.88 / $11,220.18
| Facility | | $3,388.44 | $4,570.88 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,715.35 / $5,495.41
| Professional | | $2,630.27 | $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
- $1,148.15 / $1,513.56 / $2,511.89
| Professional | | $1,148.15 | $1,513.56 | $2,511.89 |