- 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
- $2,691.53 / $4,786.30 / $9,772.37
| Professional | | $2,691.53 | $4,786.30 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $5,888.44 / $7,943.28
| Facility | | $2,691.53 | $5,888.44 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $6,309.57 / $8,912.51
| Professional | | $5,754.40 | $6,309.57 | $8,912.51 |
- 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 |