- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $705.03 / $705.03 / $705.03
| Facility | | $705.03 | $705.03 | $705.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.14 / $541.22 / $705.03
| Professional | | $524.14 | $541.22 | $705.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $401.24 / $401.24 / $401.24
| Professional | | $401.24 | $401.24 | $401.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $79.89 / $649.46 / $2,139.94
| Facility | | $79.89 | $649.46 | $2,139.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,202.34 / $3,202.34 / $3,202.34
| Professional | | $3,202.34 | $3,202.34 | $3,202.34 |