- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.46 / $129.46 / $306.30
| Professional | | $129.46 | $129.46 | $306.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $384.00 / $745.00 / $1,410.00
| Professional | | $384.00 | $745.00 | $1,410.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.53 / $263.29 / $545.94
| Professional | | $175.53 | $263.29 | $545.94 |
- 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
- $319.75 / $644.01 / $898.62
| Professional | | $319.75 | $644.01 | $898.62 |