- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,625.04 / $3,625.04 / $3,625.04
| Professional | | $3,625.04 | $3,625.04 | $3,625.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,587.01 / $5,587.01 / $5,587.01
| Facility | | $5,587.01 | $5,587.01 | $5,587.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.05 / $5,587.01 / $9,435.00
| Professional | | $615.05 | $5,587.01 | $9,435.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,683.57 / $2,968.89 / $4,706.78
| Professional | | $1,683.57 | $2,968.89 | $4,706.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,126.57 / $2,487.88 / $4,725.70
| Professional | | $2,126.57 | $2,487.88 | $4,725.70 |