- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.24 / $4,168.24 / $4,168.24
| Professional | | $4,168.24 | $4,168.24 | $4,168.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,704.40 / $3,704.40 / $3,704.40
| Facility | | $3,704.40 | $3,704.40 | $3,704.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.55 / $3,704.40 / $12,836.25
| Professional | | $782.55 | $3,704.40 | $12,836.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,505.76 / $4,418.77 / $7,005.37
| Professional | | $2,505.76 | $4,418.77 | $7,005.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,758.41 / $3,130.20 / $6,129.80
| Professional | | $2,758.41 | $3,130.20 | $6,129.80 |