- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $393.26 / $394.29 / $587.24
| Professional | | $393.26 | $394.29 | $587.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,125.00 / $1,350.00 / $2,089.00
| Professional | | $1,125.00 | $1,350.00 | $2,089.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.61 / $748.06 / $1,122.08
| Professional | | $440.61 | $748.06 | $1,122.08 |
- 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
- $451.52 / $818.38 / $1,497.61
| Professional | | $451.52 | $818.38 | $1,497.61 |