- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.62 / $287.62 / $383.82
| Professional | | $287.62 | $287.62 | $383.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $739.00 / $969.00 / $1,500.00
| Professional | | $739.00 | $969.00 | $1,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $378.54 / $529.54 / $907.54
| Professional | | $378.54 | $529.54 | $907.54 |
- 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
- $531.29 / $1,177.95 / $1,503.49
| Professional | | $531.29 | $1,177.95 | $1,503.49 |