- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,623.41 / $7,943.28
| Facility | | $4,265.80 | $5,623.41 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $5,754.40 / $14,791.08
| Professional | | $3,090.30 | $5,754.40 | $14,791.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,623.41 / $9,120.11
| Facility | | $3,019.95 | $5,623.41 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $7,762.47 / $9,120.11
| Professional | | $6,025.60 | $7,762.47 | $9,120.11 |
- 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 |