- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,458.79 / $4,458.79 / $5,573.49
| Professional | | $4,458.79 | $4,458.79 | $5,573.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,416.04 / $7,055.10 / $7,055.10
| Facility | | $5,416.04 | $7,055.10 | $7,055.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,673.00 / $11,256.18 / $11,256.18
| Professional | | $2,673.00 | $11,256.18 | $11,256.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,078.39 / $2,078.39 / $3,496.94
| Facility | | $2,078.39 | $2,078.39 | $3,496.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,673.00 / $3,426.17 / $3,973.39
| Professional | | $2,673.00 | $3,426.17 | $3,973.39 |