- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.77 / $303.39 / $458.96
| Professional | | $209.77 | $303.39 | $458.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $538.00 / $832.00 / $1,627.00
| Professional | | $538.00 | $832.00 | $1,627.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.73 / $466.64 / $861.92
| Professional | | $287.73 | $466.64 | $861.92 |
- 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
- $445.42 / $781.51 / $1,788.60
| Professional | | $445.42 | $781.51 | $1,788.60 |