- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,840.62 / $4,840.62 / $5,585.33
| Professional | | $4,840.62 | $4,840.62 | $5,585.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,553.03 / $6,553.03 / $7,290.71
| Facility | | $6,553.03 | $6,553.03 | $7,290.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,783.71 / $5,646.85 / $6,749.62
| Professional | | $4,783.71 | $5,646.85 | $6,749.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,553.03 / $6,553.03 / $7,290.71
| Facility | | $6,553.03 | $6,553.03 | $7,290.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,783.71 / $6,553.03 / $6,749.62
| Professional | | $4,783.71 | $6,553.03 | $6,749.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,431.12 / $6,922.19 / $11,467.41
| Professional | | $3,431.12 | $6,922.19 | $11,467.41 |