- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,002.20 / $1,002.20 / $1,002.20
| Professional | | $1,002.20 | $1,002.20 | $1,002.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,978.93 / $4,978.93 / $4,978.93
| Facility | | $4,978.93 | $4,978.93 | $4,978.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $725.31 / $4,978.93 / $7,947.72
| Professional | | $725.31 | $4,978.93 | $7,947.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,978.93 / $6,501.46 / $10,596.96
| Facility | | $4,978.93 | $6,501.46 | $10,596.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $725.31 / $4,978.93 / $7,947.72
| Professional | | $725.31 | $4,978.93 | $7,947.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,901.24 / $2,901.24 / $4,835.39
| Professional | | $2,901.24 | $2,901.24 | $4,835.39 |