- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,773.51 / $6,611.00 / $11,611.47
| Facility | | $3,773.51 | $6,611.00 | $11,611.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $498.40 / $868.91 / $1,527.48
| Professional | | $498.40 | $868.91 | $1,527.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $790.20 / $1,335.44 / $5,567.24
| Facility | | $790.20 | $1,335.44 | $5,567.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,045.29 / $1,529.82 / $2,932.27
| Facility | | $1,045.29 | $1,529.82 | $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 |