- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,469.31 / $2,469.31 / $2,469.31
| Professional | | $2,469.31 | $2,469.31 | $2,469.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,775.22 / $4,775.22 / $4,775.22
| Facility | | $4,775.22 | $4,775.22 | $4,775.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.41 / $4,775.22 / $9,011.25
| Professional | | $615.41 | $4,775.22 | $9,011.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,638.97 / $4,653.67 / $7,377.77
| Professional | | $2,638.97 | $4,653.67 | $7,377.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,469.31 / $3,840.72 / $5,487.35
| Professional | | $2,469.31 | $3,840.72 | $5,487.35 |