- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,936.64 / $2,936.64 / $2,936.64
| Professional | | $2,936.64 | $2,936.64 | $2,936.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,626.76 / $3,626.76 / $3,626.76
| Facility | | $3,626.76 | $3,626.76 | $3,626.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $387.52 / $3,626.76 / $5,715.00
| Professional | | $387.52 | $3,626.76 | $5,715.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,113.42 / $1,963.45 / $3,112.79
| Professional | | $1,113.42 | $1,963.45 | $3,112.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $369.80 / $1,853.92 / $4,551.50
| Professional | | $369.80 | $1,853.92 | $4,551.50 |