- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $6,606.93 / $8,128.31
| Facility | | $1,548.82 | $6,606.93 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,951.21 / $6,606.93
| Professional | | $1,621.81 | $2,951.21 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,715.35 / $6,606.93
| Facility | | $2,630.27 | $3,715.35 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,801.89 / $5,754.40
| Professional | | $3,630.78 | $3,801.89 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $5,248.07 / $7,585.78
| Facility | | $2,884.03 | $5,248.07 | $7,585.78 |