- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $573.46 / $573.46 / $573.46
| Professional | | $573.46 | $573.46 | $573.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,072.47 / $1,072.47 / $1,072.47
| Professional | | $1,072.47 | $1,072.47 | $1,072.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $1,072.47 / $1,072.47
| Professional | | $100.00 | $1,072.47 | $1,072.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,506.45 / $1,506.45 / $1,506.45
| Facility | | $1,506.45 | $1,506.45 | $1,506.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $570.67 / $816.54 / $1,408.06
| Professional | | $570.67 | $816.54 | $1,408.06 |