- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $359.97 / $359.97 / $359.97
| Professional | | $359.97 | $359.97 | $359.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $655.00 / $786.00 / $1,147.00
| Professional | | $655.00 | $786.00 | $1,147.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $482.02 / $608.46 / $850.54
| Professional | | $482.02 | $608.46 | $850.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $557.15 / $1,114.08 / $1,393.93
| Professional | | $557.15 | $1,114.08 | $1,393.93 |