- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $4,786.30 / $7,079.46
| Facility | | $2,089.30 | $4,786.30 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,513.56 / $3,388.44
| Professional | | $870.96 | $1,513.56 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,548.13 / $7,079.46
| Facility | | $1,778.28 | $3,548.13 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,754.23 / $3,162.28
| Professional | | $2,398.83 | $2,754.23 | $3,162.28 |
- 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 |