- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $517.29 / $517.29 / $550.00
| Facility | | $517.29 | $517.29 | $550.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $517.29 / $517.29 / $605.00
| Professional | | $517.29 | $517.29 | $605.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.27 / $236.35 / $408.88
| Facility | | $177.27 | $236.35 | $408.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $50.00
| Professional | | $40.00 | $40.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $400.00 / $400.00 / $400.00
| Professional | | $400.00 | $400.00 | $400.00 |