- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $6,025.60 / $7,943.28
| Facility | | $2,041.74 | $6,025.60 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,137.96 / $3,801.89
| Professional | | $1,148.15 | $2,137.96 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,238.72 / $4,677.35
| Facility | | $1,258.93 | $2,238.72 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,818.38 / $3,388.44
| Professional | | $2,137.96 | $2,818.38 | $3,388.44 |
- 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 |