- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,070.70 / $5,070.70 / $5,850.80
| Professional | | $5,070.70 | $5,070.70 | $5,850.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,503.37 / $7,503.37 / $7,637.26
| Facility | | $7,503.37 | $7,503.37 | $7,637.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,477.46 / $5,867.38 / $7,998.97
| Professional | | $5,477.46 | $5,867.38 | $7,998.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,503.37 / $7,503.37 / $7,637.26
| Facility | | $7,503.37 | $7,503.37 | $7,637.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,477.46 / $7,503.37 / $7,998.97
| Professional | | $5,477.46 | $7,503.37 | $7,998.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,455.96 / $6,155.28 / $12,012.48
| Professional | | $3,455.96 | $6,155.28 | $12,012.48 |