- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.29 / $503.29 / $503.29
| Professional | | $503.29 | $503.29 | $503.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,774.74 / $2,774.74 / $2,774.74
| Professional | | $2,774.74 | $2,774.74 | $2,774.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $390.00 / $390.00 / $390.00
| Facility | | $390.00 | $390.00 | $390.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.50 / $390.00 / $397.80
| Professional | | $331.50 | $390.00 | $397.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $503.29 / $503.29 / $603.95
| Facility | | $503.29 | $503.29 | $603.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $365.95 / $394.10
| Facility | | $100.00 | $365.95 | $394.10 |