- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,589.09 / $3,589.09 / $4,486.37
| Professional | | $3,589.09 | $3,589.09 | $4,486.37 |
- 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
- $5,083.49 / $5,083.49 / $5,083.49
| Facility | | $5,083.49 | $5,083.49 | $5,083.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,960.24 / $4,610.51 / $8,385.44
| Professional | | $1,960.24 | $4,610.51 | $8,385.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,960.24 / $2,744.35 / $3,556.68
| Facility | | $1,960.24 | $2,744.35 | $3,556.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,960.24 / $3,114.59 / $4,610.51
| Professional | | $1,960.24 | $3,114.59 | $4,610.51 |