- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.26 / $211.80 / $301.05
| Professional | | $195.26 | $211.80 | $301.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $543.00 / $652.00 / $1,008.00
| Professional | | $543.00 | $652.00 | $1,008.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.86 / $351.84 / $507.47
| Professional | | $218.86 | $351.84 | $507.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.35 / $426.97 / $877.80
| Professional | | $243.35 | $426.97 | $877.80 |