- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.37 / $172.37 / $272.73
| Professional | | $172.37 | $172.37 | $272.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $435.00 / $673.00 / $1,046.00
| Professional | | $435.00 | $673.00 | $1,046.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.50 / $354.30 / $621.80
| Professional | | $209.50 | $354.30 | $621.80 |
- 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
- $363.55 / $640.76 / $1,054.68
| Professional | | $363.55 | $640.76 | $1,054.68 |