- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,193.12 / $4,193.12 / $4,193.12
| Professional | | $4,193.12 | $4,193.12 | $4,193.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,442.44 / $9,739.87 / $24,819.47
| Facility | | $6,442.44 | $9,739.87 | $24,819.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,294.16 / $4,294.16 / $6,554.10
| Professional | | $4,294.16 | $4,294.16 | $6,554.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,442.44 / $9,739.87 / $24,819.47
| Facility | | $6,442.44 | $9,739.87 | $24,819.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,604.44 / $5,106.38 / $7,370.79
| Professional | | $3,604.44 | $5,106.38 | $7,370.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,209.96 / $4,209.96 / $4,209.96
| Professional | | $4,209.96 | $4,209.96 | $4,209.96 |