- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,152.06 / $4,604.83 / $8,042.03
| Facility | | $3,152.06 | $4,604.83 | $8,042.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $465.56 / $772.93 / $1,218.11
| Professional | | $465.56 | $772.93 | $1,218.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $819.38 / $1,330.76 / $12,013.25
| Facility | | $819.38 | $1,330.76 | $12,013.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $801.00 / $1,466.33 / $4,164.35
| Facility | | $801.00 | $1,466.33 | $4,164.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,732.00 / $8,342.00
| Facility | | $4,217.00 | $5,732.00 | $8,342.00 |