- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.59 / $291.42 / $364.56
| Professional | | $201.59 | $291.42 | $364.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $580.00 / $897.00 / $1,426.00
| Professional | | $580.00 | $897.00 | $1,426.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.39 / $423.62 / $724.89
| Professional | | $253.39 | $423.62 | $724.89 |
- 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
- $348.25 / $597.00 / $1,182.73
| Professional | | $348.25 | $597.00 | $1,182.73 |