- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.00 / $1,195.00 / $1,195.00
| Professional | | $1,195.00 | $1,195.00 | $1,195.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $510.39 / $510.39 / $611.51
| Professional | | $510.39 | $510.39 | $611.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $906.54 / $2,547.38
| Facility | | $100.00 | $906.54 | $2,547.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.68 / $224.52 / $336.05
| Professional | | $149.68 | $224.52 | $336.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.68 / $224.52 / $336.05
| Professional | | $149.68 | $224.52 | $336.05 |