- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $5,370.32 / $7,943.28
| Facility | | $1,230.27 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,454.71 / $5,888.44
| Professional | | $1,288.25 | $2,454.71 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,162.28 / $7,079.46
| Facility | | $1,862.09 | $3,162.28 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,235.94 / $4,897.79
| Professional | | $2,951.21 | $3,235.94 | $4,897.79 |
- 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 |