- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.00 / $317.23 / $409.96
| Professional | | $217.00 | $317.23 | $409.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $613.00 / $948.00 / $1,604.00
| Professional | | $613.00 | $948.00 | $1,604.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.67 / $452.92 / $775.28
| Professional | | $278.67 | $452.92 | $775.28 |
- 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
- $364.75 / $644.79 / $1,338.48
| Professional | | $364.75 | $644.79 | $1,338.48 |