- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.33 / $231.33 / $231.33
| Professional | | $231.33 | $231.33 | $231.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $526.00 / $593.00 / $712.00
| Professional | | $526.00 | $593.00 | $712.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $351.50 / $363.05 / $558.02
| Professional | | $351.50 | $363.05 | $558.02 |
- 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
- $403.15 / $608.40 / $967.58
| Professional | | $403.15 | $608.40 | $967.58 |