- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $6,025.60 / $6,760.83
| Professional | | $5,495.41 | $6,025.60 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $7,079.46 / $7,079.46
| Facility | | $5,128.61 | $7,079.46 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,897.79 / $5,128.61
| Professional | | $4,365.16 | $4,897.79 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $4,897.79
| Professional | | $4,897.79 | $4,897.79 | $4,897.79 |