- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,736.53 / $2,736.53 / $2,736.53
| Professional | | $2,736.53 | $2,736.53 | $2,736.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,899.25 / $5,899.25 / $5,899.25
| Facility | | $5,899.25 | $5,899.25 | $5,899.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $462.00 / $462.00 / $5,183.32
| Professional | | $462.00 | $462.00 | $5,183.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $664.59 / $664.59 / $664.59
| Professional | | $664.59 | $664.59 | $664.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Professional | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,332.64 / $4,390.66 / $5,899.25
| Professional | | $2,332.64 | $4,390.66 | $5,899.25 |