- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,370.32 / $7,943.28
| Facility | | $2,290.87 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,398.83 / $6,165.95
| Professional | | $1,258.93 | $2,398.83 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,951.21 / $6,025.60
| Facility | | $1,380.38 | $2,951.21 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,090.30 / $3,630.78
| Professional | | $2,511.89 | $3,090.30 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,248.07 / $7,943.28
| Facility | | $1,949.84 | $5,248.07 | $7,943.28 |