- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.54 / $273.49 / $360.49
| Professional | | $207.54 | $273.49 | $360.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $636.00 / $914.00 / $1,414.00
| Professional | | $636.00 | $914.00 | $1,414.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.58 / $413.70 / $705.27
| Professional | | $256.58 | $413.70 | $705.27 |
- 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
- $350.52 / $589.42 / $1,148.41
| Professional | | $350.52 | $589.42 | $1,148.41 |