- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,880.90 / $17,750.90 / $17,750.90
| Professional | | $3,880.90 | $17,750.90 | $17,750.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,381.56 / $5,381.56 / $5,381.56
| Facility | | $5,381.56 | $5,381.56 | $5,381.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,376.14 / $5,381.56 / $5,381.56
| Professional | | $4,376.14 | $5,381.56 | $5,381.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,381.56 / $6,401.20 / $6,602.67
| Facility | | $5,381.56 | $6,401.20 | $6,602.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,302.61 / $4,678.78 / $7,146.30
| Professional | | $3,302.61 | $4,678.78 | $7,146.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,022.47 / $6,076.80 / $9,439.61
| Professional | | $5,022.47 | $6,076.80 | $9,439.61 |