- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,219.13 / $4,038.82 / $4,438.26
| Facility | | $2,219.13 | $4,038.82 | $4,438.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,753.11 / $2,418.85 / $4,216.35
| Professional | | $1,753.11 | $2,418.85 | $4,216.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,328.70 / $3,328.70 / $3,328.70
| Facility | | $3,328.70 | $3,328.70 | $3,328.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,549.86 / $2,549.86 / $3,187.33
| Professional | | $2,549.86 | $2,549.86 | $3,187.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.03 / $1,220.52 / $3,328.70
| Professional | | $932.03 | $1,220.52 | $3,328.70 |