- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.05 / $336.05 / $673.50
| Professional | | $336.05 | $336.05 | $673.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $405.00 / $405.00 / $413.10
| Facility | | $405.00 | $405.00 | $413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $344.25 / $344.25 / $413.10
| Professional | | $344.25 | $344.25 | $413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,241.00 / $3,241.00 / $3,907.00
| Professional | | $3,241.00 | $3,241.00 | $3,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $637.50 / $637.50 / $637.50
| Professional | | $637.50 | $637.50 | $637.50 |