- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.20 / $285.20 / $301.50
| Professional | | $285.20 | $285.20 | $301.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $835.46 / $943.20
| Facility | | $0.02 | $835.46 | $943.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $539.84 / $539.84 / $539.84
| Professional | | $539.84 | $539.84 | $539.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,205.01 / $1,205.01 / $1,205.01
| Facility | | $1,205.01 | $1,205.01 | $1,205.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.12 / $231.57 / $587.64
| Professional | | $171.12 | $231.57 | $587.64 |