- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,249.19 / $2,249.19 / $2,249.19
| Professional | | $2,249.19 | $2,249.19 | $2,249.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,592.00 / $2,592.00 / $2,592.00
| Facility | | $2,592.00 | $2,592.00 | $2,592.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.95 / $2,592.00 / $3,993.75
| Professional | | $267.95 | $2,592.00 | $3,993.75 |
- 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
- $1,277.72 / $1,277.72 / $2,491.73
| Professional | | $1,277.72 | $1,277.72 | $2,491.73 |