- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $371.54
| Professional | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $251.19 / $389.05
| Facility | | $100.00 | $251.19 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $229.09 / $489.78
| Professional | | $165.96 | $229.09 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $19,498.45
| Facility | | $1,995.26 | $1,995.26 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,570.40
| Professional | | $2,570.40 | $2,570.40 | $2,570.40 |