- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,981.07 / $6,760.83
| Facility | | $2,041.74 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,238.72 / $4,168.69
| Professional | | $1,230.27 | $2,238.72 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,467.37 / $7,762.47
| Facility | | $1,698.24 | $3,467.37 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,019.95 / $4,365.16
| Professional | | $2,570.40 | $3,019.95 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $6,309.57 / $8,912.51
| Facility | | $3,801.89 | $6,309.57 | $8,912.51 |