- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $532.00 / $562.40 / $623.20
| Professional | | $532.00 | $562.40 | $623.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $805.62 / $895.13 / $934.80
| Facility | | $805.62 | $895.13 | $934.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.00 / $1,007.00 / $1,007.00
| Professional | | $1,007.00 | $1,007.00 | $1,007.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,247.02 / $2,247.02 / $2,247.02
| Facility | | $2,247.02 | $2,247.02 | $2,247.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.20 / $456.00 / $1,216.00
| Professional | | $319.20 | $456.00 | $1,216.00 |