- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $5,370.32 / $7,943.28
| Facility | | $2,344.23 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,290.87 / $5,248.07
| Professional | | $1,288.25 | $2,290.87 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,398.83 / $4,073.80
| Facility | | $1,380.38 | $2,398.83 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $3,801.89
| Professional | | $2,398.83 | $3,235.94 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $4,897.79 / $7,413.10
| Facility | | $1,318.26 | $4,897.79 | $7,413.10 |