- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.89 / $319.89 / $319.89
| Professional | | $319.89 | $319.89 | $319.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $623.00 / $748.00 / $935.00
| Professional | | $623.00 | $748.00 | $935.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.23 / $533.86 / $758.56
| Professional | | $440.23 | $533.86 | $758.56 |
- 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
- $520.86 / $825.03 / $1,276.43
| Professional | | $520.86 | $825.03 | $1,276.43 |