- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.05 / $336.05 / $336.05
| Professional | | $336.05 | $336.05 | $336.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,133.73 / $3,133.73 / $3,133.73
| Professional | | $3,133.73 | $3,133.73 | $3,133.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $405.00 / $405.00 / $405.00
| Facility | | $405.00 | $405.00 | $405.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $344.25 / $405.00 / $937.50
| Professional | | $344.25 | $405.00 | $937.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $336.05 / $336.05 / $403.26
| Facility | | $336.05 | $336.05 | $403.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $347.75 / $374.50
| Facility | | $100.00 | $347.75 | $374.50 |