- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $2,454.71 / $6,606.93
| Facility | | $912.01 | $2,454.71 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,168.69 / $6,606.93
| Professional | | $2,570.40 | $4,168.69 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,011.87 / $8,128.31
| Facility | | $3,162.28 | $5,011.87 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.13 / $602.56 / $1,659.59
| Facility | | $89.13 | $602.56 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.04 / $616.60 / $1,659.59
| Facility | | $138.04 | $616.60 | $1,659.59 |