- 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
- $1,202.26 / $2,089.30 / $6,025.60
| Professional | | $1,202.26 | $2,089.30 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,818.38 / $7,079.46
| Facility | | $1,905.46 | $2,818.38 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,818.38 / $3,981.07
| Professional | | $2,630.27 | $2,818.38 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,248.07 / $7,413.10
| Facility | | $2,137.96 | $5,248.07 | $7,413.10 |