- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,370.32 / $7,943.28
| Facility | | $3,981.07 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,890.45 / $8,511.38
| Professional | | $2,187.76 | $3,890.45 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,981.07 / $6,606.93
| Facility | | $2,137.96 | $3,981.07 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,495.41 / $6,606.93
| Professional | | $3,801.89 | $5,495.41 | $6,606.93 |
- 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 |