- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,248.07 / $8,511.38
| Professional | | $4,168.69 | $5,248.07 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $7,943.28 / $14,791.08
| Facility | | $7,943.28 | $7,943.28 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $11,220.18
| Professional | | $6,760.83 | $6,760.83 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $6,760.83 / $12,302.69
| Facility | | $5,888.44 | $6,760.83 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,570.88 / $6,760.83
| Professional | | $2,951.21 | $4,570.88 | $6,760.83 |