- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $361.35 / $361.35 / $361.35
| Professional | | $361.35 | $361.35 | $361.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $658.00 / $790.00 / $1,152.00
| Professional | | $658.00 | $790.00 | $1,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $483.88 / $611.16 / $839.15
| Professional | | $483.88 | $611.16 | $839.15 |
- 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
- $559.91 / $903.03 / $1,401.84
| Professional | | $559.91 | $903.03 | $1,401.84 |