- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,307.57 / $5,838.33 / $6,800.16
| Professional | | $5,307.57 | $5,838.33 | $6,800.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,134.16 / $7,134.16 / $7,134.16
| Facility | | $7,134.16 | $7,134.16 | $7,134.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,412.91 / $4,935.97 / $5,098.00
| Professional | | $4,412.91 | $4,935.97 | $5,098.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,098.00 / $5,098.00 / $5,098.00
| Facility | | $5,098.00 | $5,098.00 | $5,098.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,381.32 / $4,935.97 / $8,183.61
| Professional | | $4,381.32 | $4,935.97 | $8,183.61 |