- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $322.85 / $322.85 / $374.06
| Professional | | $322.85 | $322.85 | $374.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $595.00 / $683.00 / $1,025.00
| Professional | | $595.00 | $683.00 | $1,025.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $395.04 / $536.27 / $727.39
| Professional | | $395.04 | $536.27 | $727.39 |
- 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
- $475.20 / $788.51 / $1,256.65
| Professional | | $475.20 | $788.51 | $1,256.65 |