- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,426.64 / $5,962.30 / $6,201.87
| Facility | | $5,426.64 | $5,962.30 | $6,201.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,168.22 / $5,426.64 / $6,977.11
| Professional | | $5,168.22 | $5,426.64 | $6,977.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,808.96 / $2,808.96 / $3,089.86
| Facility | | $2,808.96 | $2,808.96 | $3,089.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,256.79 / $5,168.22 / $5,168.22
| Facility | | $2,256.79 | $5,168.22 | $5,168.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,168.22 / $5,168.22 / $5,168.22
| Professional | | $5,168.22 | $5,168.22 | $5,168.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,961.50 / $5,168.22 / $6,615.33
| Professional | | $4,961.50 | $5,168.22 | $6,615.33 |