- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $5,370.32 / $7,943.28
| Facility | | $1,621.81 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,819.70 / $6,309.57
| Professional | | $1,023.29 | $1,819.70 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,511.89 / $7,079.46
| Facility | | $1,778.28 | $2,511.89 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $3,467.37
| Professional | | $2,344.23 | $2,344.23 | $3,467.37 |
- 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 |