- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,904.07 / $4,904.07 / $5,210.58
| Professional | | $4,904.07 | $4,904.07 | $5,210.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,210.58 / $5,414.91 / $5,721.42
| Facility | | $5,210.58 | $5,414.91 | $5,721.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,517.08 / $5,517.08 / $5,517.08
| Professional | | $5,517.08 | $5,517.08 | $5,517.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,210.58 / $5,210.58 / $5,210.58
| Facility | | $5,210.58 | $5,210.58 | $5,210.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,210.58 / $5,210.58 / $5,210.58
| Professional | | $5,210.58 | $5,210.58 | $5,210.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,108.41 / $5,108.41 / $6,130.09
| Professional | | $5,108.41 | $5,108.41 | $6,130.09 |