- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,293.04 / $3,293.04 / $3,293.04
| Professional | | $3,293.04 | $3,293.04 | $3,293.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,124.25 / $4,124.25 / $4,124.25
| Facility | | $4,124.25 | $4,124.25 | $4,124.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $441.07 / $4,124.25 / $6,506.25
| Professional | | $441.07 | $4,124.25 | $6,506.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,267.28 / $2,234.77 / $3,542.94
| Professional | | $1,267.28 | $2,234.77 | $3,542.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,099.16 / $2,232.88 / $3,707.92
| Professional | | $2,099.16 | $2,232.88 | $3,707.92 |