- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,165.95 / $6,165.95 / $7,413.10
| Professional | | $6,165.95 | $6,165.95 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $54.95 / $4,365.16
| Facility | | $54.95 | $54.95 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $8,511.38
| Professional | | $8,511.38 | $8,511.38 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,122.02 / $2,951.21
| Facility | | $776.25 | $1,122.02 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,778.28 / $2,238.72
| Professional | | $1,445.44 | $1,778.28 | $2,238.72 |