- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,217.00 / $1,217.00 / $2,722.70
| Professional | | $1,217.00 | $1,217.00 | $2,722.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,363.10 / $2,363.10 / $2,363.10
| Professional | | $2,363.10 | $2,363.10 | $2,363.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $303.33 / $303.33 / $303.33
| Facility | | $303.33 | $303.33 | $303.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.33 / $303.33 / $303.33
| Professional | | $303.33 | $303.33 | $303.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.71 / $341.91 / $2,098.62
| Professional | | $129.71 | $341.91 | $2,098.62 |