- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.00 / $755.68 / $893.51
| Professional | | $720.00 | $755.68 | $893.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $900.00 / $900.00 / $900.00
| Professional | | $900.00 | $900.00 | $900.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $306.10 / $306.10 / $306.10
| Facility | | $306.10 | $306.10 | $306.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.54 / $519.54 / $649.44
| Professional | | $519.54 | $519.54 | $649.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $751.07 / $751.07 / $751.07
| Professional | | $751.07 | $751.07 | $751.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $755.68 / $812.28 / $893.51
| Professional | | $755.68 | $812.28 | $893.51 |