- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.51 / $193.51 / $362.73
| Professional | | $193.51 | $193.51 | $362.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.00 / $475.00 / $860.00
| Professional | | $380.00 | $475.00 | $860.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.33 / $384.91 / $647.65
| Professional | | $266.33 | $384.91 | $647.65 |
- 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
- $439.44 / $719.28 / $1,098.23
| Professional | | $439.44 | $719.28 | $1,098.23 |