- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,785.60 / $4,785.60 / $4,785.60
| Professional | | $4,785.60 | $4,785.60 | $4,785.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,300.15 / $5,300.15 / $5,406.15
| Facility | | $5,300.15 | $5,300.15 | $5,406.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.47 / $5,300.15 / $14,737.50
| Professional | | $898.47 | $5,300.15 | $14,737.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,876.91 / $5,073.26 / $8,042.98
| Professional | | $2,876.91 | $5,073.26 | $8,042.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $953.43 / $3,593.88 / $6,926.20
| Professional | | $953.43 | $3,593.88 | $6,926.20 |