- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.00 / $858.40 / $951.20
| Professional | | $812.00 | $858.40 | $951.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $898.46 / $898.46 / $1,426.80
| Facility | | $898.46 | $898.46 | $1,426.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $898.46 / $898.46
| Professional | | $0.02 | $898.46 | $898.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.28 / $2,162.48 / $2,236.66
| Professional | | $14.28 | $2,162.48 | $2,236.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $487.20 / $696.00 / $1,673.07
| Professional | | $487.20 | $696.00 | $1,673.07 |