- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,370.32 / $7,943.28
| Facility | | $1,949.84 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,398.83 / $9,772.37
| Professional | | $1,348.96 | $2,398.83 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,162.28 / $7,079.46
| Facility | | $1,949.84 | $3,162.28 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,162.28 / $4,570.88
| Professional | | $3,019.95 | $3,162.28 | $4,570.88 |
- 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 |