- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $572.04 / $591.10 / $645.00
| Facility | | $572.04 | $591.10 | $645.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $816.40 / $1,493.49 / $1,493.49
| Facility | | $816.40 | $1,493.49 | $1,493.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $451.80 / $451.80 / $451.80
| Facility | | $451.80 | $451.80 | $451.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $425.15 / $602.84 / $2,001.94
| Professional | | $425.15 | $602.84 | $2,001.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |