- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $5,370.32 / $7,943.28
| Facility | | $2,187.76 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,238.72 / $4,365.16
| Professional | | $1,230.27 | $2,238.72 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,344.23 / $3,981.07
| Facility | | $1,318.26 | $2,344.23 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,019.95 / $3,548.13
| Professional | | $2,290.87 | $3,019.95 | $3,548.13 |
- 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 |