- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.30 / $1,448.30 / $2,436.38
| Professional | | $1,448.30 | $1,448.30 | $2,436.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.37 / $198.37 / $198.37
| Professional | | $198.37 | $198.37 | $198.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.00 / $750.00 / $1,500.00
| Professional | | $750.00 | $750.00 | $1,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $70.00
| Professional | | $40.00 | $40.00 | $70.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.09 / $78.09 / $78.09
| Professional | | $78.09 | $78.09 | $78.09 |