- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.00 / $555.00 / $615.00
| Professional | | $525.00 | $555.00 | $615.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $1,537.92 / $1,736.25
| Facility | | $0.02 | $1,537.92 | $1,736.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $993.75 / $993.75 / $993.75
| Professional | | $993.75 | $993.75 | $993.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,217.11 / $2,217.11 / $2,217.11
| Facility | | $2,217.11 | $2,217.11 | $2,217.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.00 / $450.00 / $1,081.73
| Professional | | $315.00 | $450.00 | $1,081.73 |