- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $769.50 / $769.50 / $961.88
| Professional | | $769.50 | $769.50 | $961.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Professional | | $150.00 | $150.00 | $150.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $61,755.25 / $61,755.25 / $61,755.25
| Facility | | $61,755.25 | $61,755.25 | $61,755.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,225.30 / $2,225.30 / $2,225.30
| Professional | | $2,225.30 | $2,225.30 | $2,225.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.09 / $726.82 / $726.82
| Professional | | $436.09 | $726.82 | $726.82 |