- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $5,370.32 / $7,943.28
| Facility | | $2,570.40 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,511.89 / $5,623.41
| Professional | | $1,412.54 | $2,511.89 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,754.23 / $4,570.88
| Facility | | $1,513.56 | $2,754.23 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,467.37 / $4,168.69
| Professional | | $2,691.53 | $3,467.37 | $4,168.69 |
- 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 |