- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,752.08 / $1,752.08 / $1,752.08
| Professional | | $1,752.08 | $1,752.08 | $1,752.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,387.48 / $2,387.48 / $2,387.48
| Facility | | $2,387.48 | $2,387.48 | $2,387.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.77 / $2,387.48 / $3,993.75
| Professional | | $251.77 | $2,387.48 | $3,993.75 |
- 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
- $1,129.32 / $1,188.08 / $2,509.60
| Professional | | $1,129.32 | $1,188.08 | $2,509.60 |