- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,817.60 / $6,035.76 / $6,181.20
| Professional | | $5,817.60 | $6,035.76 | $6,181.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,169.91 / $1,169.91 / $2,569.46
| Facility | | $1,169.91 | $1,169.91 | $2,569.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,169.91 / $6,181.20 / $6,181.20
| Professional | | $1,169.91 | $6,181.20 | $6,181.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $939.10 / $1,192.73 / $7,272.00
| Facility | | $939.10 | $1,192.73 | $7,272.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,079.79 / $6,661.76 / $6,939.34
| Professional | | $1,079.79 | $6,661.76 | $6,939.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,060.00 / $6,060.00 / $6,060.00
| Professional | | $6,060.00 | $6,060.00 | $6,060.00 |