- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.40 / $198.40 / $315.37
| Professional | | $198.40 | $198.40 | $315.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $587.00 / $950.00 / $1,461.00
| Professional | | $587.00 | $950.00 | $1,461.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.43 / $380.35 / $555.89
| Professional | | $260.43 | $380.35 | $555.89 |
- 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
- $374.70 / $586.47 / $1,079.02
| Professional | | $374.70 | $586.47 | $1,079.02 |