- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,313.68 / $4,313.68 / $4,313.68
| Professional | | $4,313.68 | $4,313.68 | $4,313.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,608.68 / $7,608.68 / $7,608.68
| Facility | | $7,608.68 | $7,608.68 | $7,608.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.92 / $7,608.68 / $12,641.25
| Professional | | $816.92 | $7,608.68 | $12,641.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,401.92 / $4,235.64 / $6,715.04
| Professional | | $2,401.92 | $4,235.64 | $6,715.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,530.71 / $3,357.32 / $5,623.80
| Professional | | $2,530.71 | $3,357.32 | $5,623.80 |