- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $5,370.32 / $7,943.28
| Facility | | $1,737.80 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,819.70 / $3,890.45
| Professional | | $1,000.00 | $1,819.70 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,905.46 / $3,388.44
| Facility | | $1,071.52 | $1,905.46 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,398.83 / $2,884.03
| Professional | | $1,819.70 | $2,398.83 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $4,897.79 / $7,413.10
| Facility | | $1,318.26 | $4,897.79 | $7,413.10 |