- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,467.18 / $4,467.18 / $5,154.43
| Professional | | $4,467.18 | $4,467.18 | $5,154.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,541.83 / $6,541.83 / $6,728.28
| Facility | | $6,541.83 | $6,541.83 | $6,728.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,775.54 / $4,988.62 / $6,738.08
| Professional | | $4,775.54 | $4,988.62 | $6,738.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,541.83 / $6,541.83 / $6,728.28
| Facility | | $6,541.83 | $6,541.83 | $6,728.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,775.54 / $6,541.83 / $6,738.08
| Professional | | $4,775.54 | $6,541.83 | $6,738.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,044.63 / $6,020.97 / $10,582.76
| Professional | | $3,044.63 | $6,020.97 | $10,582.76 |