- 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
- $1,043.54 / $1,942.95 / $11,100.08
| Professional | | $1,043.54 | $1,942.95 | $11,100.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.55 / $1,101.21 / $2,067.25
| Facility | | $812.55 | $1,101.21 | $2,067.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $250.44 / $1,242.00 / $4,406.00
| Facility | | $250.44 | $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 |