- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,007.68 / $4,007.68 / $4,007.68
| Professional | | $4,007.68 | $4,007.68 | $4,007.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,539.60 / $6,539.60 / $6,539.60
| Facility | | $6,539.60 | $6,539.60 | $6,539.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.44 / $6,539.60 / $12,341.25
| Professional | | $752.44 | $6,539.60 | $12,341.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,409.34 / $4,248.73 / $6,735.79
| Professional | | $2,409.34 | $4,248.73 | $6,735.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,652.17 / $3,009.76 / $5,893.70
| Professional | | $2,652.17 | $3,009.76 | $5,893.70 |