- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.29 / $348.29 / $428.92
| Professional | | $348.29 | $348.29 | $428.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $680.00 / $837.00 / $1,046.00
| Professional | | $680.00 | $837.00 | $1,046.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $480.45 / $611.52 / $991.36
| Professional | | $480.45 | $611.52 | $991.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $693.00 / $1,103.91 / $1,684.32
| Professional | | $693.00 | $1,103.91 | $1,684.32 |