- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.18 / $227.18 / $298.12
| Professional | | $227.18 | $227.18 | $298.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $521.00 / $705.00 / $1,090.00
| Professional | | $521.00 | $705.00 | $1,090.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.77 / $430.41 / $742.94
| Professional | | $289.77 | $430.41 | $742.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.39 / $561.40 / $1,206.47
| Professional | | $422.39 | $561.40 | $1,206.47 |