- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $4,786.30 / $7,079.46
| Facility | | $1,621.81 | $4,786.30 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,445.44 / $4,570.88
| Professional | | $954.99 | $1,445.44 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,570.40 / $7,079.46
| Facility | | $1,380.38 | $2,570.40 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,344.23 / $2,754.23
| Professional | | $2,041.74 | $2,344.23 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,495.41 / $7,762.47
| Facility | | $3,162.28 | $5,495.41 | $7,762.47 |