- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,843.38 / $5,843.38 / $7,394.96
| Professional | | $5,843.38 | $5,843.38 | $7,394.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,180.63 / $7,608.68 / $7,608.68
| Facility | | $5,180.63 | $7,608.68 | $7,608.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.70 / $7,608.68 / $7,608.68
| Professional | | $906.70 | $7,608.68 | $7,608.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,313.68 / $5,843.38 / $7,394.96
| Facility | | $4,313.68 | $5,843.38 | $7,394.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,660.90 / $6,660.90 / $6,660.90
| Professional | | $6,660.90 | $6,660.90 | $6,660.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.23 / $2,219.26 / $4,109.74
| Professional | | $308.23 | $2,219.26 | $4,109.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,246.46 / $3,441.24 / $4,835.74
| Professional | | $2,246.46 | $3,441.24 | $4,835.74 |