- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $702.30 / $702.30 / $702.30
| Professional | | $702.30 | $702.30 | $702.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $923.73 / $923.73 / $923.73
| Facility | | $923.73 | $923.73 | $923.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $582.54 / $663.06 / $4,214.47
| Facility | | $582.54 | $663.06 | $4,214.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.65 / $960.14 / $5,609.51
| Professional | | $103.65 | $960.14 | $5,609.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $830.00 / $1,156.94 / $1,366.64
| Facility | | $830.00 | $1,156.94 | $1,366.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.65 / $776.94 / $1,339.56
| Professional | | $103.65 | $776.94 | $1,339.56 |