- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,834.13 / $5,909.48 / $13,841.56
| Facility | | $2,834.13 | $5,909.48 | $13,841.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.24 / $151.13 / $151.13
| Professional | | $51.24 | $151.13 | $151.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,551.47 / $4,813.14 / $9,035.51
| Facility | | $3,551.47 | $4,813.14 | $9,035.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $289.08 / $810.50 / $4,406.00
| Facility | | $289.08 | $810.50 | $4,406.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,031.00 / $1,775.00 / $4,406.00
| Facility | | $1,031.00 | $1,775.00 | $4,406.00 |