- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,657.92 / $13,008.90 / $13,008.90
| Professional | | $2,657.92 | $13,008.90 | $13,008.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,155.92 / $4,155.92 / $4,155.92
| Facility | | $4,155.92 | $4,155.92 | $4,155.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,708.40 / $4,155.92 / $4,511.08
| Professional | | $2,708.40 | $4,155.92 | $4,511.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,045.20 / $4,407.64 / $4,726.04
| Facility | | $2,045.20 | $4,407.64 | $4,726.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,499.36 / $3,749.43 / $5,408.20
| Professional | | $2,499.36 | $3,749.43 | $5,408.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,538.62 / $4,442.12 / $7,253.83
| Professional | | $3,538.62 | $4,442.12 | $7,253.83 |