- 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
- $2,884.03 / $5,128.61 / $12,589.25
| Professional | | $2,884.03 | $5,128.61 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $6,165.95 / $8,128.31
| Facility | | $2,818.38 | $6,165.95 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $6,760.83 / $8,709.64
| Professional | | $5,754.40 | $6,760.83 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,248.07 / $7,413.10
| Facility | | $2,137.96 | $5,248.07 | $7,413.10 |