- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,535.76 / $3,535.76 / $3,535.76
| Professional | | $3,535.76 | $3,535.76 | $3,535.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,303.28 / $4,303.28 / $4,303.28
| Facility | | $4,303.28 | $4,303.28 | $4,303.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $459.38 / $4,303.28 / $6,776.25
| Professional | | $459.38 | $4,303.28 | $6,776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,319.87 / $2,327.52 / $3,689.97
| Professional | | $1,319.87 | $2,327.52 | $3,689.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,209.71 / $2,209.71 / $5,088.20
| Professional | | $2,209.71 | $2,209.71 | $5,088.20 |