- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,623.41 / $7,943.28
| Facility | | $4,265.80 | $5,623.41 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $7,244.36 / $14,454.40
| Professional | | $3,981.07 | $7,244.36 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $7,244.36 / $11,481.54
| Facility | | $3,388.44 | $7,244.36 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,120.11 / $9,332.54 / $12,022.64
| Professional | | $9,120.11 | $9,332.54 | $12,022.64 |
- 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 |