- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.62 / $393.08 / $497.90
| Professional | | $389.62 | $393.08 | $497.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.00 / $900.00 / $1,361.00
| Professional | | $750.00 | $900.00 | $1,361.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.20 / $765.36 / $1,082.66
| Professional | | $529.20 | $765.36 | $1,082.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.00 / $293.00 / $3,239.00
| Facility | | $293.00 | $293.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $552.72 / $785.68 / $1,281.81
| Professional | | $552.72 | $785.68 | $1,281.81 |