- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.75 / $402.75 / $458.81
| Professional | | $402.75 | $402.75 | $458.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,186.00 / $1,917.00 / $2,165.00
| Professional | | $1,186.00 | $1,917.00 | $2,165.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $458.33 / $595.83 / $870.83
| Professional | | $458.33 | $595.83 | $870.83 |
- 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
- $462.80 / $794.23 / $1,440.39
| Professional | | $462.80 | $794.23 | $1,440.39 |