- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.00 / $500.00 / $990.00
| Professional | | $500.00 | $500.00 | $990.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,104.00 / $2,104.00 / $2,104.00
| Professional | | $2,104.00 | $2,104.00 | $2,104.00 |
- 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
- $736.38 / $920.47 / $1,037.11
| Professional | | $736.38 | $920.47 | $1,037.11 |
- 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
- $736.38 / $920.47 / $1,037.11
| Professional | | $736.38 | $920.47 | $1,037.11 |