- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $765.20 / $765.20 / $765.20
| Professional | | $765.20 | $765.20 | $765.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.15 / $199.15 / $225.70
| Professional | | $199.15 | $199.15 | $225.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,216.68 / $1,216.68 / $1,216.68
| Facility | | $1,216.68 | $1,216.68 | $1,216.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $919.20 / $1,606.00 / $2,293.00
| Professional | | $919.20 | $1,606.00 | $2,293.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $593.64 / $1,511.10 / $1,732.80
| Professional | | $593.64 | $1,511.10 | $1,732.80 |