- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,055.14 / $5,055.14 / $5,832.86
| Professional | | $5,055.14 | $5,055.14 | $5,832.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,652.12 / $6,652.12 / $6,652.12
| Facility | | $6,652.12 | $6,652.12 | $6,652.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,856.05 / $4,856.05 / $6,851.68
| Professional | | $4,856.05 | $4,856.05 | $6,851.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,652.12 / $6,652.12 / $6,652.12
| Facility | | $6,652.12 | $6,652.12 | $6,652.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,856.05 / $6,652.12 / $6,851.68
| Professional | | $4,856.05 | $6,652.12 | $6,851.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,445.37 / $6,933.27 / $11,975.64
| Professional | | $3,445.37 | $6,933.27 | $11,975.64 |