- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $474.33 / $474.33 / $474.33
| Professional | | $474.33 | $474.33 | $474.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $360.90 / $360.90 / $360.90
| Facility | | $360.90 | $360.90 | $360.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.77 / $360.90 / $1,233.75
| Professional | | $306.77 | $360.90 | $1,233.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $931.33 / $1,614.31
| Professional | | $60.00 | $931.33 | $1,614.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.82 / $726.27 / $1,178.41
| Professional | | $549.82 | $726.27 | $1,178.41 |