- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,152.06 / $4,964.00 / $7,412.32
| Facility | | $3,152.06 | $4,964.00 | $7,412.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $378.56 / $600.21 / $1,639.26
| Professional | | $378.56 | $600.21 | $1,639.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.26 / $1,013.90 / $7,896.02
| Facility | | $645.26 | $1,013.90 | $7,896.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $760.94 / $1,075.26 / $2,961.89
| Facility | | $760.94 | $1,075.26 | $2,961.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,341.00 / $6,588.00 / $10,320.00
| Facility | | $5,341.00 | $6,588.00 | $10,320.00 |