- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.01 / $260.01 / $260.01
| Professional | | $260.01 | $260.01 | $260.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.07 / $303.22 / $406.54
| Professional | | $247.07 | $303.22 | $406.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $400.42 / $9,713.25 / $20,403.84
| Facility | | $400.42 | $9,713.25 | $20,403.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.00 / $758.00 / $758.00
| Professional | | $758.00 | $758.00 | $758.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,351.47 / $3,910.04 / $5,384.69
| Facility | | $3,351.47 | $3,910.04 | $5,384.69 |