- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,289.84 / $2,289.84 / $2,289.84
| Professional | | $2,289.84 | $2,289.84 | $2,289.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,254.90 / $2,254.90 / $2,254.90
| Facility | | $2,254.90 | $2,254.90 | $2,254.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.70 / $2,254.90 / $3,993.75
| Professional | | $267.70 | $2,254.90 | $3,993.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.53 / $1.53 / $60.00
| Professional | | $1.53 | $1.53 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,285.80 / $1,481.45 / $2,518.26
| Professional | | $1,285.80 | $1,481.45 | $2,518.26 |