- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.98 / $252.80 / $388.46
| Professional | | $212.98 | $252.80 | $388.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $713.00 / $856.00 / $1,325.00
| Professional | | $713.00 | $856.00 | $1,325.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.87 / $398.68 / $586.41
| Professional | | $270.87 | $398.68 | $586.41 |
- 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
- $273.62 / $481.96 / $917.39
| Professional | | $273.62 | $481.96 | $917.39 |