- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,370.32 / $7,943.28
| Facility | | $4,168.69 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,801.89 / $6,165.95
| Professional | | $2,290.87 | $3,801.89 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,981.07 / $6,760.83
| Facility | | $2,041.74 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,623.41 / $6,760.83
| Professional | | $3,019.95 | $5,623.41 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $4,897.79 / $7,413.10
| Facility | | $1,318.26 | $4,897.79 | $7,413.10 |