- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,188.71 / $4,033.00 / $7,266.91
| Facility | | $1,188.71 | $4,033.00 | $7,266.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $342.84 / $506.34 / $1,316.20
| Professional | | $342.84 | $506.34 | $1,316.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $492.25 / $892.80 / $4,871.77
| Facility | | $492.25 | $892.80 | $4,871.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $689.65 / $1,147.10 / $1,622.05
| Facility | | $689.65 | $1,147.10 | $1,622.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,770.00 / $4,663.00 / $7,305.00
| Facility | | $1,770.00 | $4,663.00 | $7,305.00 |