- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,370.32 / $7,943.28
| Facility | | $4,265.80 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $5,128.61 / $11,481.54
| Professional | | $2,754.23 | $5,128.61 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,011.87 / $8,128.31
| Facility | | $2,951.21 | $5,011.87 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $6,918.31 / $8,128.31
| Professional | | $5,370.32 | $6,918.31 | $8,128.31 |
- 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 |