- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.54 / $906.54 / $906.54
| Professional | | $906.54 | $906.54 | $906.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $431.83 / $453.42 / $595.92
| Professional | | $431.83 | $453.42 | $595.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $486.32 / $510.39 / $611.51
| Professional | | $486.32 | $510.39 | $611.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $906.54 / $1,042.52 / $1,918.20
| Facility | | $906.54 | $1,042.52 | $1,918.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.29 / $219.75 / $268.83
| Professional | | $163.29 | $219.75 | $268.83 |