- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.05 / $667.57 / $695.78
| Professional | | $336.05 | $667.57 | $695.78 |
- 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 / $405.00 / $750.00
| Professional | | $344.25 | $405.00 | $750.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,927.21 / $3,927.21 / $3,927.21
| Professional | | $3,927.21 | $3,927.21 | $3,927.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $637.50 / $637.50 / $750.00
| Professional | | $637.50 | $637.50 | $750.00 |