- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,981.07 / $6,760.83
| Facility | | $1,659.59 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,995.26 / $4,677.35
| Professional | | $1,122.02 | $1,995.26 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,818.38 / $7,079.46
| Facility | | $1,995.26 | $2,818.38 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,818.38 / $4,073.80
| Professional | | $2,511.89 | $2,818.38 | $4,073.80 |
- 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 |