- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,691.74 / $4,691.74 / $5,864.68
| Professional | | $4,691.74 | $4,691.74 | $5,864.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,907.09 / $4,722.91 / $8,905.14
| Facility | | $2,907.09 | $4,722.91 | $8,905.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,885.00 / $17,046.00 / $17,046.00
| Professional | | $3,885.00 | $17,046.00 | $17,046.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,885.00 / $3,885.00 / $3,885.00
| Facility | | $3,885.00 | $3,885.00 | $3,885.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,105.00 / $4,433.35 / $4,538.91
| Professional | | $3,105.00 | $4,433.35 | $4,538.91 |