- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $502.51 / $502.51 / $502.51
| Professional | | $502.51 | $502.51 | $502.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $515.73 / $703.68 / $912.79
| Facility | | $515.73 | $703.68 | $912.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.00 / $4.00 / $1,249.59
| Professional | | $4.00 | $4.00 | $1,249.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $604.75 / $1,140.44 / $12,000.00
| Facility | | $604.75 | $1,140.44 | $12,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,111.90 / $2,111.90 / $2,136.89
| Professional | | $2,111.90 | $2,111.90 | $2,136.89 |