- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,343.54 / $3,343.54 / $3,343.54
| Professional | | $3,343.54 | $3,343.54 | $3,343.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,900.00 / $5,900.00 / $6,018.00
| Facility | | $5,900.00 | $5,900.00 | $6,018.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $763.91 / $5,900.00 / $11,268.75
| Professional | | $763.91 | $5,900.00 | $11,268.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,299.43 / $5,805.77 / $7,095.55
| Professional | | $3,299.43 | $5,805.77 | $7,095.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $728.97 / $4,876.80 / $7,430.08
| Professional | | $728.97 | $4,876.80 | $7,430.08 |