- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,265.92 / $5,805.69 / $6,268.95
| Professional | | $5,265.92 | $5,805.69 | $6,268.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,969.00 / $3,969.00 / $3,969.00
| Facility | | $3,969.00 | $3,969.00 | $3,969.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,373.65 / $3,373.65 / $3,373.65
| Professional | | $3,373.65 | $3,373.65 | $3,373.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $534.91 / $607.69 / $4,051.28
| Facility | | $534.91 | $607.69 | $4,051.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,032.50 / $3,174.84 / $3,963.30
| Professional | | $2,032.50 | $3,174.84 | $3,963.30 |