- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.18 / $526.49 / $641.70
| Professional | | $303.18 | $526.49 | $641.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,026.14 / $1,026.14 / $1,026.14
| Professional | | $1,026.14 | $1,026.14 | $1,026.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $654.00 / $654.75 / $654.75
| Facility | | $654.00 | $654.75 | $654.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.35 / $654.75 / $750.00
| Professional | | $44.35 | $654.75 | $750.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.19 / $396.98 / $825.02
| Professional | | $265.19 | $396.98 | $825.02 |