- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $814.22 / $814.22 / $814.22
| Professional | | $814.22 | $814.22 | $814.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,775.22 / $4,775.22 / $4,775.22
| Facility | | $4,775.22 | $4,775.22 | $4,775.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.41 / $4,775.22 / $6,778.49
| Professional | | $615.41 | $4,775.22 | $6,778.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,389.88 / $6,658.56 / $10,845.58
| Facility | | $4,389.88 | $6,658.56 | $10,845.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.41 / $4,775.22 / $6,778.49
| Professional | | $615.41 | $4,775.22 | $6,778.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,457.03 / $3,840.72 / $6,401.20
| Professional | | $3,457.03 | $3,840.72 | $6,401.20 |