- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $487.50 / $487.50 / $487.50
| Professional | | $487.50 | $487.50 | $487.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,104.00 / $1,245.00 / $1,494.00
| Professional | | $1,104.00 | $1,245.00 | $1,494.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $719.86 / $744.75 / $1,141.34
| Professional | | $719.86 | $744.75 | $1,141.34 |
- 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
- $710.07 / $1,602.08 / $1,978.67
| Professional | | $710.07 | $1,602.08 | $1,978.67 |