- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.43 / $253.60 / $330.88
| Professional | | $153.43 | $253.60 | $330.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $430.00 / $665.00 / $1,259.00
| Professional | | $430.00 | $665.00 | $1,259.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.82 / $319.88 / $587.25
| Professional | | $194.82 | $319.88 | $587.25 |
- 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
- $312.24 / $498.48 / $1,021.68
| Professional | | $312.24 | $498.48 | $1,021.68 |