- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.38 / $308.50 / $350.70
| Professional | | $221.38 | $308.50 | $350.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $578.00 / $856.00 / $1,325.00
| Professional | | $578.00 | $856.00 | $1,325.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.58 / $499.09 / $895.23
| Professional | | $295.58 | $499.09 | $895.23 |
- 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
- $378.39 / $622.91 / $1,417.67
| Professional | | $378.39 | $622.91 | $1,417.67 |