- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $4,786.30 / $7,079.46
| Facility | | $1,905.46 | $4,786.30 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,380.38 / $2,884.03
| Professional | | $794.33 | $1,380.38 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,019.95 / $7,079.46
| Facility | | $1,621.81 | $3,019.95 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,511.89 / $2,951.21
| Professional | | $1,778.28 | $2,511.89 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,754.40 / $7,585.78
| Facility | | $3,311.31 | $5,754.40 | $7,585.78 |