- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $5,370.32 / $7,943.28
| Facility | | $2,238.72 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,754.23 / $6,025.60
| Professional | | $1,548.82 | $2,754.23 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,630.78 / $7,079.46
| Facility | | $2,187.76 | $3,630.78 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,630.78 / $5,370.32
| Professional | | $3,467.37 | $3,630.78 | $5,370.32 |
- 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 |