- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,934.48 / $3,934.48 / $3,934.48
| Professional | | $3,934.48 | $3,934.48 | $3,934.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,818.66 / $3,818.66 / $3,818.66
| Facility | | $3,818.66 | $3,818.66 | $3,818.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $738.67 / $3,818.66 / $12,116.25
| Professional | | $738.67 | $3,818.66 | $12,116.25 |
- 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
- $2,333.88 / $2,954.68 / $4,924.47
| Professional | | $2,333.88 | $2,954.68 | $4,924.47 |