- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $955.98 / $955.98 / $955.98
| Professional | | $955.98 | $955.98 | $955.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,160.00 / $2,160.00 / $2,160.00
| Facility | | $2,160.00 | $2,160.00 | $2,160.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.39 / $2,160.00 / $4,050.00
| Professional | | $259.39 | $2,160.00 | $4,050.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $60.00
| Professional | | $60.00 | $60.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.81 / $1,469.64 / $2,124.11
| Professional | | $1,174.81 | $1,469.64 | $2,124.11 |