- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $5,370.32 / $7,943.28
| Facility | | $1,905.46 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,949.84 / $4,570.88
| Professional | | $1,202.26 | $1,949.84 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,019.95 / $7,244.36
| Facility | | $1,949.84 | $3,019.95 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,019.95 / $3,981.07
| Professional | | $2,630.27 | $3,019.95 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,248.07 / $7,413.10
| Facility | | $2,137.96 | $5,248.07 | $7,413.10 |