- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $379.16 / $379.16 / $379.16
| Professional | | $379.16 | $379.16 | $379.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.00 / $1,790.00 / $2,148.00
| Professional | | $1,107.00 | $1,790.00 | $2,148.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $387.62 / $523.28 / $755.85
| Professional | | $387.62 | $523.28 | $755.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $384.65 / $752.26 / $1,210.31
| Professional | | $384.65 | $752.26 | $1,210.31 |