- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,981.07 / $6,760.83
| Facility | | $2,818.38 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $8,317.64
| Professional | | $1,698.24 | $2,511.89 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $4,265.80 / $7,413.10
| Facility | | $2,187.76 | $4,265.80 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,073.80 / $4,897.79
| Professional | | $3,467.37 | $4,073.80 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $6,309.57 / $8,912.51
| Facility | | $4,168.69 | $6,309.57 | $8,912.51 |