- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,806.28 / $4,877.39 / $5,527.34
| Professional | | $4,806.28 | $4,877.39 | $5,527.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,732.85 / $8,732.85 / $8,732.85
| Facility | | $8,732.85 | $8,732.85 | $8,732.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,374.98 / $6,374.98 / $8,732.85
| Professional | | $6,374.98 | $6,374.98 | $8,732.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,544.86 / $5,544.86 / $5,544.86
| Facility | | $5,544.86 | $5,544.86 | $5,544.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,338.46 / $6,334.98 / $8,906.35
| Professional | | $5,338.46 | $6,334.98 | $8,906.35 |