- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,370.32 / $7,943.28
| Facility | | $4,265.80 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $4,466.84 / $9,549.93
| Professional | | $2,630.27 | $4,466.84 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $5,888.44 / $7,413.10
| Facility | | $2,398.83 | $5,888.44 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $6,165.95 / $9,332.54
| Professional | | $5,754.40 | $6,165.95 | $9,332.54 |
- 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 |