- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $305.75 / $449.78 / $491.58
| Professional | | $305.75 | $449.78 | $491.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $850.00 / $1,020.00 / $1,577.00
| Professional | | $850.00 | $1,020.00 | $1,577.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $342.15 / $549.76 / $1,056.20
| Professional | | $342.15 | $549.76 | $1,056.20 |
- 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
- $325.88 / $607.80 / $1,308.10
| Professional | | $325.88 | $607.80 | $1,308.10 |