- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,002.55 / $5,002.55 / $6,253.18
| Professional | | $5,002.55 | $5,002.55 | $6,253.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,456.00 / $4,456.00 / $8,969.79
| Facility | | $4,456.00 | $4,456.00 | $8,969.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,329.63 / $4,156.00 / $16,276.95
| Professional | | $3,329.63 | $4,156.00 | $16,276.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,984.50 / $2,492.53 / $4,456.00
| Facility | | $1,984.50 | $2,492.53 | $4,456.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,895.28 / $3,447.32 / $4,630.89
| Professional | | $1,895.28 | $3,447.32 | $4,630.89 |