- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $560.04 / $560.04 / $560.04
| Professional | | $560.04 | $560.04 | $560.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,100.00 / $1,320.00 / $1,649.00
| Professional | | $1,100.00 | $1,320.00 | $1,649.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $751.60 / $943.82 / $1,300.23
| Professional | | $751.60 | $943.82 | $1,300.23 |
- 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
- $875.05 / $1,404.36 / $2,175.36
| Professional | | $875.05 | $1,404.36 | $2,175.36 |