- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,108.67 / $5,653.69 / $10,493.60
| Professional | | $5,108.67 | $5,653.69 | $10,493.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,351.01 / $5,351.01 / $11,869.03
| Facility | | $5,351.01 | $5,351.01 | $11,869.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,686.85 / $4,686.85 / $5,351.01
| Professional | | $4,686.85 | $4,686.85 | $5,351.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,351.01 / $5,351.01 / $11,869.03
| Facility | | $5,351.01 | $5,351.01 | $11,869.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,686.85 / $5,084.79 / $6,632.34
| Professional | | $4,686.85 | $5,084.79 | $6,632.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,686.85 / $4,686.85 / $4,686.85
| Professional | | $4,686.85 | $4,686.85 | $4,686.85 |