- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.40 / $503.40 / $503.40
| Professional | | $503.40 | $503.40 | $503.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $629.25 / $780.00 / $1,611.00
| Professional | | $629.25 | $780.00 | $1,611.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,007.01 / $1,007.01 / $1,007.01
| Facility | | $1,007.01 | $1,007.01 | $1,007.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $578.20 / $578.20 / $722.75
| Professional | | $578.20 | $578.20 | $722.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.43 / $211.43 / $503.40
| Professional | | $211.43 | $211.43 | $503.40 |