- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,981.07 / $6,760.83
| Facility | | $2,511.89 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,511.89 / $4,786.30
| Professional | | $1,380.38 | $2,511.89 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,754.23 / $4,897.79
| Facility | | $1,479.11 | $2,754.23 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,467.37 / $4,073.80
| Professional | | $2,570.40 | $3,467.37 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $4,897.79 / $7,413.10
| Facility | | $1,318.26 | $4,897.79 | $7,413.10 |