- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.56 / $275.83 / $372.78
| Professional | | $253.56 | $275.83 | $372.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $703.00 / $844.00 / $1,304.00
| Professional | | $703.00 | $844.00 | $1,304.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.94 / $455.14 / $874.63
| Professional | | $286.94 | $455.14 | $874.63 |
- 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
- $315.60 / $553.74 / $1,073.80
| Professional | | $315.60 | $553.74 | $1,073.80 |