- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,391.12 / $2,391.12 / $2,391.12
| Professional | | $2,391.12 | $2,391.12 | $2,391.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,671.66 / $2,671.66 / $2,671.66
| Facility | | $2,671.66 | $2,671.66 | $2,671.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.64 / $2,671.66 / $4,515.00
| Professional | | $286.64 | $2,671.66 | $4,515.00 |
- 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
- $1,361.32 / $1,361.32 / $3,449.10
| Professional | | $1,361.32 | $1,361.32 | $3,449.10 |