- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,233.33 / $4,277.00 / $7,153.83
| Facility | | $1,233.33 | $4,277.00 | $7,153.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $414.61 / $775.93 / $1,418.72
| Professional | | $414.61 | $775.93 | $1,418.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $649.13 / $1,131.94 / $5,567.24
| Facility | | $649.13 | $1,131.94 | $5,567.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $906.10 / $1,274.38 / $2,932.27
| Facility | | $906.10 | $1,274.38 | $2,932.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,327.00 / $8,342.00
| Facility | | $4,217.00 | $5,327.00 | $8,342.00 |