- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,370.32 / $7,943.28
| Facility | | $2,137.96 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,398.83 / $5,495.41
| Professional | | $1,445.44 | $2,398.83 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,311.31 / $7,079.46
| Facility | | $1,621.81 | $3,311.31 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,388.44 / $3,981.07
| Professional | | $2,344.23 | $3,388.44 | $3,981.07 |
- 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 |