- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.05 / $113.84 / $293.69
| Professional | | $73.05 | $113.84 | $293.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.00 / $341.00 / $1,167.00
| Professional | | $220.00 | $341.00 | $1,167.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.76 / $196.63 / $540.62
| Professional | | $103.76 | $196.63 | $540.62 |
- 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
- $285.24 / $483.84 / $901.57
| Professional | | $285.24 | $483.84 | $901.57 |