- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,378.74 / $7,203.68 / $7,203.68
| Professional | | $5,378.74 | $7,203.68 | $7,203.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,109.46 / $5,109.46 / $5,109.46
| Facility | | $5,109.46 | $5,109.46 | $5,109.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,343.04 / $4,343.04 / $4,343.04
| Professional | | $4,343.04 | $4,343.04 | $4,343.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,109.46 / $5,109.46 / $5,109.46
| Facility | | $5,109.46 | $5,109.46 | $5,109.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,836.69 / $5,576.80 / $7,091.73
| Professional | | $2,836.69 | $5,576.80 | $7,091.73 |