- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,370.32 / $7,943.28
| Facility | | $3,162.28 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,311.31 / $7,762.47
| Professional | | $1,995.26 | $3,311.31 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,011.87 / $7,244.36
| Facility | | $2,951.21 | $5,011.87 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $5,248.07 / $7,762.47
| Professional | | $4,570.88 | $5,248.07 | $7,762.47 |
- 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 |