- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,921.20 / $5,606.96 / $5,624.22
| Facility | | $4,921.20 | $5,606.96 | $5,624.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,686.85 / $4,921.20 / $6,327.25
| Professional | | $4,686.85 | $4,921.20 | $6,327.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,152.03 / $3,152.03 / $3,467.23
| Facility | | $3,152.03 | $3,152.03 | $3,467.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,995.61 / $4,686.85 / $4,686.85
| Facility | | $2,995.61 | $4,686.85 | $4,686.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,686.85 / $4,686.85 / $4,686.85
| Professional | | $4,686.85 | $4,686.85 | $4,686.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,499.38 / $4,686.85 / $6,689.87
| Professional | | $4,499.38 | $4,686.85 | $6,689.87 |