- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.45 / $311.23 / $6,300.00
| Professional | | $283.45 | $311.23 | $6,300.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $803.00 / $964.00 / $1,490.00
| Professional | | $803.00 | $964.00 | $1,490.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $305.58 / $515.71 / $710.84
| Professional | | $305.58 | $515.71 | $710.84 |
- 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
- $332.01 / $555.85 / $1,230.24
| Professional | | $332.01 | $555.85 | $1,230.24 |