- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,165.95 / $6,760.83 / $7,244.36
| Professional | | $6,165.95 | $6,760.83 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,715.35
| Professional | | $3,162.28 | $3,162.28 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $707.95 / $4,677.35
| Facility | | $371.54 | $707.95 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,715.35 / $5,495.41
| Professional | | $2,570.40 | $3,715.35 | $5,495.41 |