- 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
- $7,634.97 / $7,634.97 / $7,634.97
| Facility | | $7,634.97 | $7,634.97 | $7,634.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,448.00 / $16,929.27 / $16,929.27
| Professional | | $4,448.00 | $16,929.27 | $16,929.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,049.53 / $2,574.19 / $5,076.38
| Facility | | $2,049.53 | $2,574.19 | $5,076.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,049.53 / $3,521.87 / $5,076.38
| Professional | | $2,049.53 | $3,521.87 | $5,076.38 |