- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,370.32 / $7,943.28
| Facility | | $3,162.28 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,162.28 / $8,912.51
| Professional | | $1,778.28 | $3,162.28 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,235.94 / $5,370.32
| Facility | | $1,905.46 | $3,235.94 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,365.16 / $5,128.61
| Professional | | $3,311.31 | $4,365.16 | $5,128.61 |
- 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 |