- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $5,370.32 / $7,943.28
| Facility | | $1,778.28 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,778.28 / $4,897.79
| Professional | | $1,000.00 | $1,778.28 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,949.84 / $3,715.35
| Facility | | $1,071.52 | $1,949.84 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,454.71 / $2,884.03
| Professional | | $1,862.09 | $2,454.71 | $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 |