- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,993.72 / $3,706.14 / $3,955.04
| Facility | | $2,993.72 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,605.86 / $1,605.86 / $1,811.41
| Professional | | $1,605.86 | $1,605.86 | $1,811.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,309.43 / $8,813.52 / $11,244.38
| Facility | | $4,309.43 | $8,813.52 | $11,244.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.30 / $2,116.30 / $2,116.30
| Professional | | $2,116.30 | $2,116.30 | $2,116.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $3,447.00 / $7,350.00
| Facility | | $2,654.00 | $3,447.00 | $7,350.00 |