- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $276.36 / $276.36 / $276.36
| Professional | | $276.36 | $276.36 | $276.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $424.00 / $506.00 / $607.00
| Professional | | $424.00 | $506.00 | $607.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $375.10 / $455.93 / $648.26
| Professional | | $375.10 | $455.93 | $648.26 |
- 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
- $416.35 / $698.03 / $1,115.41
| Professional | | $416.35 | $698.03 | $1,115.41 |