- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.72 / $1,751.72 / $1,751.72
| Professional | | $1,751.72 | $1,751.72 | $1,751.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,844.50 / $1,844.50 / $1,844.50
| Professional | | $1,844.50 | $1,844.50 | $1,844.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,080.00 / $1,080.00 / $1,080.00
| Facility | | $1,080.00 | $1,080.00 | $1,080.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $783.67 / $783.67 / $1,543.12
| Professional | | $783.67 | $783.67 | $1,543.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.00 / $24.00 / $1,751.72
| Professional | | $24.00 | $24.00 | $1,751.72 |