- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,697.60 / $4,697.60 / $4,697.60
| Professional | | $4,697.60 | $4,697.60 | $4,697.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,860.06 / $7,860.06 / $7,860.06
| Facility | | $7,860.06 | $7,860.06 | $7,860.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $814.44 / $7,860.06 / $13,008.75
| Professional | | $814.44 | $7,860.06 | $13,008.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,477.97 / $4,369.76 / $6,927.67
| Professional | | $2,477.97 | $4,369.76 | $6,927.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,070.98 / $3,564.08 / $6,824.40
| Professional | | $3,070.98 | $3,564.08 | $6,824.40 |