- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,370.32 / $7,943.28
| Facility | | $2,951.21 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,019.95 / $6,606.93
| Professional | | $1,659.59 | $3,019.95 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,162.28 / $5,128.61
| Facility | | $1,778.28 | $3,162.28 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,073.80 / $4,897.79
| Professional | | $3,090.30 | $4,073.80 | $4,897.79 |
- 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 |