- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $689.00 / $913.60 / $1,203.19
| Professional | | $689.00 | $913.60 | $1,203.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.00 / $313.00 / $313.00
| Professional | | $313.00 | $313.00 | $313.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.70 / $340.70 / $612.90
| Professional | | $340.70 | $340.70 | $612.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $406.53 / $473.49 / $802.35
| Facility | | $406.53 | $473.49 | $802.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,322.00 / $1,322.00 / $1,322.00
| Professional | | $1,322.00 | $1,322.00 | $1,322.00 |