- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.00 / $325.00 / $406.25
| Professional | | $275.00 | $325.00 | $406.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.04 / $228.02 / $373.12
| Professional | | $108.04 | $228.02 | $373.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.18 / $463.98 / $777.12
| Professional | | $226.18 | $463.98 | $777.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $909.44 / $2,613.82 / $2,613.82
| Facility | | $909.44 | $2,613.82 | $2,613.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,779.80 / $1,779.80 / $1,779.80
| Professional | | $1,779.80 | $1,779.80 | $1,779.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.69 / $432.17 / $701.37
| Professional | | $341.69 | $432.17 | $701.37 |