- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,659.59 / $2,344.23
| Facility | | $1,096.48 | $1,659.59 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,890.45 / $3,981.07
| Professional | | $3,801.89 | $3,890.45 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $7,079.46 / $9,549.93
| Facility | | $5,888.44 | $7,079.46 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $5,370.32 / $9,120.11
| Facility | | $1,698.24 | $5,370.32 | $9,120.11 |