- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $771.37 / $771.37 / $771.37
| Facility | | $771.37 | $771.37 | $771.37 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $385.69 / $385.69 / $385.69
| Facility | 52 | $385.69 | $385.69 | $385.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $826.55 / $1,284.42 / $2,224.88
| Facility | | $826.55 | $1,284.42 | $2,224.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,274.39 / $1,917.42 / $2,625.85
| Facility | | $1,274.39 | $1,917.42 | $2,625.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,004.92 / $1,430.19 / $1,657.36
| Professional | | $1,004.92 | $1,430.19 | $1,657.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |