- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.00 / $930.00 / $930.00
| Professional | | $930.00 | $930.00 | $930.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,255.31 / $1,255.31 / $1,255.31
| Facility | | $1,255.31 | $1,255.31 | $1,255.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $861.93 / $861.93 / $1,077.41
| Professional | | $861.93 | $861.93 | $1,077.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,255.31 / $1,255.31 / $1,255.31
| Facility | | $1,255.31 | $1,255.31 | $1,255.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $487.50 / $861.93 / $1,077.41
| Professional | | $487.50 | $861.93 | $1,077.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $450.00 / $450.00 / $1,050.00
| Professional | | $450.00 | $450.00 | $1,050.00 |