- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,168.22 / $5,168.22 / $8,536.02
| Professional | | $5,168.22 | $5,168.22 | $8,536.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,850.83 / $5,850.83 / $5,850.83
| Facility | | $5,850.83 | $5,850.83 | $5,850.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,875.68 / $5,624.81 / $9,374.68
| Facility | | $4,875.68 | $5,624.81 | $9,374.68 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $4,875.68 / $5,624.81 / $9,374.68
| Facility | | $4,875.68 | $5,624.81 | $9,374.68 |
- 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
- $4,878.66 / $5,168.22 / $7,950.34
| Professional | | $4,878.66 | $5,168.22 | $7,950.34 |