- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,370.32 / $7,943.28
| Facility | | $3,019.95 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,715.35 / $9,120.11
| Professional | | $2,137.96 | $3,715.35 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $5,011.87 / $7,079.46
| Facility | | $2,344.23 | $5,011.87 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $5,370.32 / $7,413.10
| Professional | | $4,897.79 | $5,370.32 | $7,413.10 |
- 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 |