- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,861.12 / $2,861.12 / $2,861.12
| Professional | | $2,861.12 | $2,861.12 | $2,861.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,349.85 / $3,349.85 / $3,349.85
| Facility | | $3,349.85 | $3,349.85 | $3,349.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.67 / $3,349.85 / $5,261.25
| Professional | | $356.67 | $3,349.85 | $5,261.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,024.80 / $1,807.18 / $2,865.04
| Professional | | $1,024.80 | $1,807.18 | $2,865.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,741.32 / $1,892.16 / $4,124.00
| Professional | | $1,741.32 | $1,892.16 | $4,124.00 |