- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,906.97 / $5,463.36 / $10,506.16
| Facility | | $3,906.97 | $5,463.36 | $10,506.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.45 / $1,439.19 / $3,908.05
| Professional | | $1,018.45 | $1,439.19 | $3,908.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,411.39 / $3,180.97 / $13,238.00
| Facility | | $1,411.39 | $3,180.97 | $13,238.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,758.00 / $3,440.32 / $6,162.95
| Facility | | $1,758.00 | $3,440.32 | $6,162.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,221.00 / $8,060.00 / $11,869.99
| Facility | | $7,221.00 | $8,060.00 | $11,869.99 |