- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $5,370.32 / $7,943.28
| Facility | | $1,819.70 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,187.76 / $4,570.88
| Professional | | $1,258.93 | $2,187.76 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,951.21 / $7,079.46
| Facility | | $1,778.28 | $2,951.21 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,951.21 / $4,168.69
| Professional | | $2,754.23 | $2,951.21 | $4,168.69 |
- 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 |