- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $5,370.32 / $7,943.28
| Facility | | $1,778.28 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,778.28 / $3,890.45
| Professional | | $1,122.02 | $1,778.28 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,951.21 / $7,244.36
| Facility | | $1,778.28 | $2,951.21 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,884.03 / $4,265.80
| Professional | | $2,454.71 | $2,884.03 | $4,265.80 |
- 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 |