- 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
- $3,090.30 / $5,370.32 / $12,302.69
| Professional | | $3,090.30 | $5,370.32 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $6,760.83 / $8,912.51
| Facility | | $2,951.21 | $6,760.83 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,918.31 / $7,244.36 / $10,471.29
| Professional | | $6,918.31 | $7,244.36 | $10,471.29 |
- 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 |