- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $991.87 / $1,053.85 / $1,053.85
| Professional | | $991.87 | $1,053.85 | $1,053.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,600.44 / $2,600.44 / $2,809.40
| Facility | | $2,600.44 | $2,600.44 | $2,809.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.85 / $1,053.85 / $1,053.85
| Professional | | $1,053.85 | $1,053.85 | $1,053.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.85 / $1,053.85 / $1,053.85
| Professional | | $1,053.85 | $1,053.85 | $1,053.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,033.20 / $1,053.85 / $3,099.60
| Professional | | $1,033.20 | $1,053.85 | $3,099.60 |