- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,241.22 / $10,431.19 / $20,928.72
| Facility | | $4,241.22 | $10,431.19 | $20,928.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.78 / $1,201.78 / $1,201.78
| Professional | | $1,201.78 | $1,201.78 | $1,201.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.31 / $3,154.44 / $6,101.70
| Facility | | $2,398.31 | $3,154.44 | $6,101.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,081.59 / $1,775.00 / $4,406.00
| Facility | | $1,081.59 | $1,775.00 | $4,406.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,056.00 / $1,527.00 / $4,317.00
| Facility | | $1,056.00 | $1,527.00 | $4,317.00 |