- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $390.38 / $394.28 / $487.97
| Professional | | $390.38 | $394.28 | $487.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Professional | | $150.00 | $150.00 | $150.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,509.35 / $6,509.35 / $6,509.35
| Facility | | $6,509.35 | $6,509.35 | $6,509.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.31 / $1,500.31 / $1,500.31
| Professional | | $1,500.31 | $1,500.31 | $1,500.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.45 / $400.56 / $546.97
| Professional | | $320.45 | $400.56 | $546.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $251.10 / $473.40
| Professional | | $5.00 | $251.10 | $473.40 |