- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.65 / $182.65 / $182.65
| Professional | | $182.65 | $182.65 | $182.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $412.00 / $465.00 / $558.00
| Professional | | $412.00 | $465.00 | $558.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $276.64 / $285.72 / $440.41
| Professional | | $276.64 | $285.72 | $440.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $273.32 / $599.66 / $761.65
| Professional | | $273.32 | $599.66 | $761.65 |