- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,851.10 / $4,851.10 / $6,063.88
| Professional | | $4,851.10 | $4,851.10 | $6,063.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,448.00 / $4,448.00 / $7,634.97
| Facility | | $4,448.00 | $4,448.00 | $7,634.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,439.46 / $3,988.04 / $16,929.27
| Professional | | $3,439.46 | $3,988.04 | $16,929.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,049.53 / $2,574.19 / $4,448.00
| Facility | | $2,049.53 | $2,574.19 | $4,448.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.35 / $3,457.11 / $4,448.00
| Professional | | $1,905.35 | $3,457.11 | $4,448.00 |