- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,357.50 / $3,357.50 / $3,357.50
| Professional | | $3,357.50 | $3,357.50 | $3,357.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.00 / $344.00 / $810.00
| Professional | | $236.00 | $344.00 | $810.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.52 / $287.58 / $691.34
| Professional | | $158.52 | $287.58 | $691.34 |
- 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
- $405.90 / $675.06 / $1,199.86
| Professional | | $405.90 | $675.06 | $1,199.86 |