- 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
- $2,951.21 / $5,495.41 / $12,302.69
| Professional | | $2,951.21 | $5,495.41 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,370.32 / $8,709.64
| Facility | | $2,951.21 | $5,370.32 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $7,413.10 / $8,912.51
| Professional | | $5,888.44 | $7,413.10 | $8,912.51 |
- 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 |