- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $5,370.32 / $7,943.28
| Facility | | $3,715.35 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,715.35 / $8,128.31
| Professional | | $1,995.26 | $3,715.35 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,715.35 / $6,165.95
| Facility | | $2,089.30 | $3,715.35 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,128.61 / $5,888.44
| Professional | | $3,981.07 | $5,128.61 | $5,888.44 |
- 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 |