- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,096.48
| Professional | | $1,047.13 | $1,047.13 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $125.89 / $1,047.13
| Professional | | $125.89 | $125.89 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Facility | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Professional | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Professional | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $1,047.13 / $1,348.96
| Professional | | $275.42 | $1,047.13 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $1,000.00 / $1,047.13
| Professional | | $125.89 | $1,000.00 | $1,047.13 |