- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.14 / $255.60 / $337.52
| Professional | | $226.14 | $255.60 | $337.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $648.00 / $778.00 / $1,204.00
| Professional | | $648.00 | $778.00 | $1,204.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.77 / $420.67 / $562.29
| Professional | | $253.77 | $420.67 | $562.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $273.52 / $479.91 / $838.50
| Professional | | $273.52 | $479.91 | $838.50 |