- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,677.35 / $7,244.36
| Professional | | $3,715.35 | $4,677.35 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,025.60 / $7,244.36
| Facility | | $6,025.60 | $6,025.60 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $8,128.31 / $11,481.54
| Professional | | $6,025.60 | $8,128.31 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,332.54 / $9,332.54 / $9,332.54
| Professional | | $9,332.54 | $9,332.54 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $9,332.54 / $10,715.19
| Professional | | $6,606.93 | $9,332.54 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,248.07 / $6,165.95
| Facility | | $5,128.61 | $5,248.07 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $6,456.54 / $10,000.00
| Professional | | $4,570.88 | $6,456.54 | $10,000.00 |