- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $5,370.32 / $7,943.28
| Facility | | $2,041.74 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,187.76 / $4,786.30
| Professional | | $1,380.38 | $2,187.76 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,235.94 / $6,606.93
| Facility | | $1,949.84 | $3,235.94 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,311.31 / $3,981.07
| Professional | | $2,884.03 | $3,311.31 | $3,981.07 |
- 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 |