- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,152.06 / $4,917.20 / $7,119.04
| Facility | | $3,152.06 | $4,917.20 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.42 / $693.78 / $1,646.99
| Professional | | $436.42 | $693.78 | $1,646.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $743.03 / $1,156.77 / $7,896.02
| Facility | | $743.03 | $1,156.77 | $7,896.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $879.00 / $1,250.27 / $2,961.89
| Facility | | $879.00 | $1,250.27 | $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 |