- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,370.32 / $7,943.28
| Facility | | $2,137.96 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,570.40 / $5,370.32
| Professional | | $1,445.44 | $2,570.40 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,388.44 / $7,079.46
| Facility | | $1,949.84 | $3,388.44 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,467.37 / $4,677.35
| Professional | | $3,090.30 | $3,467.37 | $4,677.35 |
- 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 |