- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,723.63 / $2,723.63 / $2,723.63
| Professional | | $2,723.63 | $2,723.63 | $2,723.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,623.29 / $8,623.29 / $8,623.29
| Facility | | $8,623.29 | $8,623.29 | $8,623.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,842.00 / $3,842.00 / $4,708.85
| Professional | | $3,842.00 | $3,842.00 | $4,708.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,842.00 / $3,842.00 / $3,842.00
| Facility | | $3,842.00 | $3,842.00 | $3,842.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,915.01 / $3,842.00 / $5,087.64
| Professional | | $2,915.01 | $3,842.00 | $5,087.64 |