- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $5,370.32 / $7,943.28
| Facility | | $1,905.46 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,398.83 / $5,754.40
| Professional | | $1,174.90 | $2,398.83 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,951.21 / $7,079.46
| Facility | | $1,949.84 | $2,951.21 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,884.03 / $4,365.16
| Professional | | $2,570.40 | $2,884.03 | $4,365.16 |
- 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 |