- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.35 / $284.35 / $452.19
| Professional | | $284.35 | $284.35 | $452.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $555.00 / $693.00 / $1,076.00
| Professional | | $555.00 | $693.00 | $1,076.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $391.07 / $521.52 / $863.25
| Professional | | $391.07 | $521.52 | $863.25 |
- 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
- $592.90 / $951.18 / $1,459.94
| Professional | | $592.90 | $951.18 | $1,459.94 |