- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,260.12 / $4,260.12 / $5,325.15
| Professional | | $4,260.12 | $4,260.12 | $5,325.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,113.00 / $3,113.00 / $6,613.14
| Facility | | $3,113.00 | $3,113.00 | $6,613.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,473.00 / $3,356.20 / $10,732.74
| Professional | | $2,473.00 | $3,356.20 | $10,732.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,980.69 / $3,113.00 / $3,113.00
| Facility | | $1,980.69 | $3,113.00 | $3,113.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,980.69 / $3,059.06 / $3,382.78
| Professional | | $1,980.69 | $3,059.06 | $3,382.78 |