- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,917.20 / $9,608.62 / $19,276.96
| Facility | | $4,917.20 | $9,608.62 | $19,276.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,334.15 / $1,773.03 / $1,773.03
| Professional | | $1,334.15 | $1,773.03 | $1,773.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,218.81 / $10,465.26 / $18,365.84
| Facility | | $7,218.81 | $10,465.26 | $18,365.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,032.00 / $8,632.00 / $80,553.72
| Facility | | $4,032.00 | $8,632.00 | $80,553.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,178.00 / $7,441.00 / $8,816.00
| Facility | | $6,178.00 | $7,441.00 | $8,816.00 |