- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,836.80 / $6,836.80 / $6,836.80
| Professional | | $6,836.80 | $6,836.80 | $6,836.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,155.72 / $11,155.72 / $11,155.72
| Facility | | $11,155.72 | $11,155.72 | $11,155.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,283.58 / $11,155.72 / $21,056.25
| Professional | | $1,283.58 | $11,155.72 | $21,056.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,110.06 / $7,247.85 / $11,490.50
| Professional | | $4,110.06 | $7,247.85 | $11,490.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,380.35 / $5,134.32 / $9,734.10
| Professional | | $4,380.35 | $5,134.32 | $9,734.10 |