- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.52 / $260.55 / $303.26
| Professional | | $166.52 | $260.55 | $303.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $419.00 / $648.00 / $1,012.00
| Professional | | $419.00 | $648.00 | $1,012.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.68 / $360.00 / $643.37
| Professional | | $213.68 | $360.00 | $643.37 |
- 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
- $271.06 / $482.95 / $1,066.55
| Professional | | $271.06 | $482.95 | $1,066.55 |