- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,362.06 / $3,362.06 / $5,887.87
| Professional | | $3,362.06 | $3,362.06 | $5,887.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,566.51 / $6,566.51 / $6,566.51
| Facility | | $6,566.51 | $6,566.51 | $6,566.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,566.51 / $6,566.51 / $6,566.51
| Professional | | $6,566.51 | $6,566.51 | $6,566.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,052.23 / $4,052.23 / $7,335.32
| Facility | | $4,052.23 | $4,052.23 | $7,335.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,958.13 / $2,958.13 / $4,052.23
| Professional | | $2,958.13 | $2,958.13 | $4,052.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,516.98 / $3,713.13 / $4,291.35
| Professional | | $2,516.98 | $3,713.13 | $4,291.35 |