- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,014.56 / $3,014.56 / $3,014.56
| Professional | | $3,014.56 | $3,014.56 | $3,014.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,673.00 / $2,673.00 / $2,673.00
| Facility | | $2,673.00 | $2,673.00 | $2,673.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $378.53 / $2,673.00 / $5,756.25
| Professional | | $378.53 | $2,673.00 | $5,756.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.65 / $1,900.37 / $3,012.78
| Professional | | $1,077.65 | $1,900.37 | $3,012.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,783.24 / $2,113.60 / $4,433.20
| Professional | | $1,783.24 | $2,113.60 | $4,433.20 |