- 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
- $5,173.93 / $6,613.14 / $6,613.14
| Facility | | $5,173.93 | $6,613.14 | $6,613.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,473.00 / $10,732.74 / $10,732.74
| Professional | | $2,473.00 | $10,732.74 | $10,732.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,980.69 / $1,980.69 / $3,382.78
| Facility | | $1,980.69 | $1,980.69 | $3,382.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,473.00 / $3,113.00 / $3,793.48
| Professional | | $2,473.00 | $3,113.00 | $3,793.48 |