- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $5,370.32 / $7,943.28
| Facility | | $2,398.83 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,454.71 / $5,128.61
| Professional | | $1,479.11 | $2,454.71 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,801.89 / $7,244.36
| Facility | | $2,290.87 | $3,801.89 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,801.89 / $5,754.40
| Professional | | $3,467.37 | $3,801.89 | $5,754.40 |
- 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 |