- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,679.67 / $1,679.67 / $1,679.67
| Professional | | $1,679.67 | $1,679.67 | $1,679.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,248.38 / $3,248.38 / $3,248.38
| Facility | | $3,248.38 | $3,248.38 | $3,248.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.13 / $3,248.38 / $6,123.75
| Professional | | $415.13 | $3,248.38 | $6,123.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,789.10 / $3,154.98 / $5,001.80
| Professional | | $1,789.10 | $3,154.98 | $5,001.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,679.67 / $2,596.26 / $3,732.61
| Professional | | $1,679.67 | $2,596.26 | $3,732.61 |