- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,204.28 / $4,917.20 / $7,119.04
| Facility | | $3,204.28 | $4,917.20 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $441.57 / $736.23 / $2,085.48
| Professional | | $441.57 | $736.23 | $2,085.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $739.70 / $1,234.11 / $7,896.02
| Facility | | $739.70 | $1,234.11 | $7,896.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.00 / $1,234.11 / $2,961.89
| Facility | | $933.00 | $1,234.11 | $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 |