- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $494.48 / $494.48 / $710.43
| Professional | | $494.48 | $494.48 | $710.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.00 / $2,336.00 / $3,306.00
| Professional | | $1,445.00 | $2,336.00 | $3,306.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $657.02 / $928.93 / $1,357.67
| Professional | | $657.02 | $928.93 | $1,357.67 |
- 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
- $751.76 / $1,388.89 / $2,241.19
| Professional | | $751.76 | $1,388.89 | $2,241.19 |