- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,947.43 / $4,947.43 / $4,947.43
| Professional | | $4,947.43 | $4,947.43 | $4,947.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,072.81 / $8,072.81 / $8,072.81
| Facility | | $8,072.81 | $8,072.81 | $8,072.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.85 / $8,072.81 / $15,236.25
| Professional | | $928.85 | $8,072.81 | $15,236.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,974.20 / $5,244.83 / $8,314.98
| Professional | | $2,974.20 | $5,244.83 | $8,314.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,223.80 / $3,715.40 / $7,164.00
| Professional | | $3,223.80 | $3,715.40 | $7,164.00 |