- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.87 / $373.13 / $900.00
| Professional | | $269.87 | $373.13 | $900.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $690.00 / $945.00 / $1,462.00
| Professional | | $690.00 | $945.00 | $1,462.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.25 / $502.64 / $860.47
| Professional | | $295.25 | $502.64 | $860.47 |
- 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
- $368.84 / $659.15 / $1,433.53
| Professional | | $368.84 | $659.15 | $1,433.53 |