- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.29 / $629.11 / $1,258.00
| Professional | | $503.29 | $629.11 | $1,258.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $390.00 / $390.00 / $397.80
| Facility | | $390.00 | $390.00 | $397.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.50 / $390.00 / $397.80
| Professional | | $331.50 | $390.00 | $397.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,955.45 / $2,955.45 / $2,955.45
| Professional | | $2,955.45 | $2,955.45 | $2,955.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $637.50 / $750.00 / $750.00
| Professional | | $637.50 | $750.00 | $750.00 |