- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.00 / $500.00 / $893.51
| Professional | | $500.00 | $500.00 | $893.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,486.40 / $2,486.40 / $2,503.76
| Facility | | $2,486.40 | $2,486.40 | $2,503.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.19 / $263.19 / $263.19
| Facility | | $263.19 | $263.19 | $263.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.54 / $649.44 / $977.73
| Professional | | $519.54 | $649.44 | $977.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.19 / $263.19 / $263.19
| Facility | | $263.19 | $263.19 | $263.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.54 / $649.44 / $977.73
| Professional | | $519.54 | $649.44 | $977.73 |