- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $8,912.51
| Professional | | $3,548.13 | $3,548.13 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $6,606.93
| Facility | | $5,011.87 | $5,011.87 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,715.19 / $10,715.19 / $10,715.19
| Professional | | $10,715.19 | $10,715.19 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,630.27 / $2,951.21
| Facility | | $1,737.80 | $2,630.27 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,862.09 / $2,454.71
| Professional | | $1,621.81 | $1,862.09 | $2,454.71 |