- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.10 / $456.10 / $456.10
| Professional | | $456.10 | $456.10 | $456.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,043.00 / $1,177.00 / $1,412.00
| Professional | | $1,043.00 | $1,177.00 | $1,412.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $653.53 / $702.82 / $1,097.71
| Professional | | $653.53 | $702.82 | $1,097.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $610.12 / $1,486.85 / $2,158.17
| Professional | | $610.12 | $1,486.85 | $2,158.17 |