- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.86 / $229.15 / $311.08
| Professional | | $210.86 | $229.15 | $311.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $587.00 / $704.00 / $1,090.00
| Professional | | $587.00 | $704.00 | $1,090.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.73 / $379.87 / $729.76
| Professional | | $239.73 | $379.87 | $729.76 |
- 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
- $262.80 / $419.57 / $910.80
| Professional | | $262.80 | $419.57 | $910.80 |