- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,172.55 / $4,604.83 / $8,042.03
| Facility | | $3,172.55 | $4,604.83 | $8,042.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $613.92 / $870.37 / $2,103.94
| Professional | | $613.92 | $870.37 | $2,103.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,053.47 / $2,024.52 / $10,015.53
| Facility | | $1,053.47 | $2,024.52 | $10,015.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.26 / $2,070.44 / $4,188.66
| Facility | | $1,288.26 | $2,070.44 | $4,188.66 |
- 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 |