- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $11,220.18 / $12,589.25
| Facility | | $1,202.26 | $11,220.18 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $9,332.54 / $12,882.50
| Facility | | $5,370.32 | $9,332.54 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,848.93 / $16,982.44 / $17,782.79
| Facility | | $15,848.93 | $16,982.44 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.22 / $1,071.52 / $1,584.89
| Professional | | $16.22 | $1,071.52 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $6,456.54 / $26,302.68
| Facility | | $1,445.44 | $6,456.54 | $26,302.68 |