- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.29 / $646.11 / $3,351.96
| Professional | | $503.29 | $646.11 | $3,351.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.00 / $600.00 / $600.00
| Professional | | $600.00 | $600.00 | $600.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $390.00 / $390.00 / $397.80
| Facility | | $390.00 | $390.00 | $397.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.50 / $390.00 / $397.80
| Professional | | $331.50 | $390.00 | $397.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $503.29 / $503.29 / $3,351.96
| Facility | | $503.29 | $503.29 | $3,351.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,850.00 / $5,850.00 / $5,850.00
| Professional | | $5,850.00 | $5,850.00 | $5,850.00 |