- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.40 / $187.93 / $318.39
| Professional | | $129.40 | $187.93 | $318.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.00 / $526.00 / $1,220.00
| Professional | | $340.00 | $526.00 | $1,220.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.80 / $321.24 / $628.89
| Professional | | $194.80 | $321.24 | $628.89 |
- 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
- $323.14 / $545.77 / $1,242.10
| Professional | | $323.14 | $545.77 | $1,242.10 |