- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,242.81 / $1,242.81 / $1,242.81
| Professional | | $1,242.81 | $1,242.81 | $1,242.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,225.05 / $2,225.05 / $2,225.05
| Facility | | $2,225.05 | $2,225.05 | $2,225.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.68 / $2,225.05 / $5,261.25
| Professional | | $343.68 | $2,225.05 | $5,261.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $60.00
| Professional | | $60.00 | $60.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,196.11 / $1,433.05 / $2,761.80
| Professional | | $1,196.11 | $1,433.05 | $2,761.80 |