- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,682.23 / $2,682.23 / $2,682.23
| Professional | | $2,682.23 | $2,682.23 | $2,682.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,703.06 / $1,703.06 / $1,703.06
| Facility | | $1,703.06 | $1,703.06 | $1,703.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $58.40 / $85.00
| Professional | | $50.00 | $58.40 | $85.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $65.00 / $65.00 / $1,703.06
| Facility | | $65.00 | $65.00 | $1,703.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,682.23 / $2,682.23 / $2,682.23
| Professional | | $2,682.23 | $2,682.23 | $2,682.23 |