- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $865.13 / $865.13 / $7,750.21
| Professional | | $865.13 | $865.13 | $7,750.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,786.79 / $1,786.79 / $1,786.79
| Facility | | $1,786.79 | $1,786.79 | $1,786.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.77 / $1,786.79 / $3,663.75
| Professional | | $1,518.77 | $1,786.79 | $3,663.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $60.00
| Professional | | $60.00 | $60.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $865.13 / $1,340.09 / $1,922.52
| Professional | | $865.13 | $1,340.09 | $1,922.52 |