- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,370.32 / $7,943.28
| Facility | | $1,949.84 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,949.84 / $4,168.69
| Professional | | $1,202.26 | $1,949.84 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,235.94 / $7,244.36
| Facility | | $2,290.87 | $3,235.94 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,235.94 / $4,897.79
| Professional | | $2,818.38 | $3,235.94 | $4,897.79 |
- 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 |