- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.75 / $247.16 / $364.25
| Professional | | $234.75 | $247.16 | $364.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $704.00 / $845.00 / $1,307.00
| Professional | | $704.00 | $845.00 | $1,307.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.33 / $445.21 / $715.60
| Professional | | $280.33 | $445.21 | $715.60 |
- 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
- $284.70 / $505.26 / $954.35
| Professional | | $284.70 | $505.26 | $954.35 |