- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $905.03 / $905.03 / $905.03
| Professional | | $905.03 | $905.03 | $905.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,440.00 / $1,440.00 / $1,468.80
| Facility | | $1,440.00 | $1,440.00 | $1,468.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.64 / $1,440.00 / $3,832.50
| Professional | | $233.64 | $1,440.00 | $3,832.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,126.31 / $1,978.92 / $2,422.19
| Professional | | $1,126.31 | $1,978.92 | $2,422.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $905.03 / $1,391.26 / $2,011.18
| Professional | | $905.03 | $1,391.26 | $2,011.18 |