- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,536.20 / $5,536.20 / $9,695.40
| Professional | | $5,536.20 | $5,536.20 | $9,695.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,812.90 / $10,812.90 / $10,812.90
| Professional | | $10,812.90 | $10,812.90 | $10,812.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,704.40 / $3,704.40 / $3,704.40
| Facility | | $3,704.40 | $3,704.40 | $3,704.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,704.40 / $3,704.40 / $6,026.06
| Professional | | $3,704.40 | $3,704.40 | $6,026.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,653.02 / $3,130.20 / $4,715.39
| Professional | | $2,653.02 | $3,130.20 | $4,715.39 |