- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,718.32 / $2,718.32 / $2,718.32
| Professional | | $2,718.32 | $2,718.32 | $2,718.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.40 / $2,446.40 / $2,446.40
| Facility | | $2,446.40 | $2,446.40 | $2,446.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.94 / $2,446.40 / $4,372.50
| Professional | | $286.94 | $2,446.40 | $4,372.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $789.44 / $1,392.13 / $2,211.82
| Professional | | $789.44 | $1,392.13 | $2,211.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.68 / $1,435.76 / $3,997.50
| Professional | | $260.68 | $1,435.76 | $3,997.50 |