- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $6,456.54 / $6,760.83
| Professional | | $5,623.41 | $6,456.54 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $7,585.78
| Facility | | $7,585.78 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $7,585.78
| Professional | | $6,456.54 | $6,456.54 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.09 / $851.14 / $5,754.40
| Facility | | $457.09 | $851.14 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,801.89 / $5,128.61
| Professional | | $2,691.53 | $3,801.89 | $5,128.61 |