- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,370.32 / $7,943.28
| Facility | | $3,235.94 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $4,168.69 / $8,709.64
| Professional | | $2,238.72 | $4,168.69 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $5,128.61 / $7,079.46
| Facility | | $2,344.23 | $5,128.61 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,248.07 / $7,244.36
| Professional | | $4,786.30 | $5,248.07 | $7,244.36 |
- 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 |