- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,967.88 / $3,967.88 / $4,959.84
| Professional | | $3,967.88 | $3,967.88 | $4,959.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20,066.20 / $20,066.20 / $20,066.20
| Facility | | $20,066.20 | $20,066.20 | $20,066.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,418.00 / $3,418.00 / $3,418.00
| Professional | | $3,418.00 | $3,418.00 | $3,418.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,420.53 / $4,773.14 / $5,224.93
| Facility | | $4,420.53 | $4,773.14 | $5,224.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,959.43 / $4,788.20 / $10,005.64
| Professional | | $3,959.43 | $4,788.20 | $10,005.64 |