- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,463.36 / $10,431.19 / $20,928.72
| Facility | | $5,463.36 | $10,431.19 | $20,928.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.71 / $238.71 / $238.71
| Professional | | $238.71 | $238.71 | $238.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,551.47 / $5,148.63 / $9,035.51
| Facility | | $3,551.47 | $5,148.63 | $9,035.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $289.08 / $1,242.00 / $4,406.00
| Facility | | $289.08 | $1,242.00 | $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 |