- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.46 / $251.46 / $251.46
| Professional | | $251.46 | $251.46 | $251.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $621.00 / $621.00 / $621.00
| Facility | | $621.00 | $621.00 | $621.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $621.00 / $621.00 / $621.00
| Professional | | $621.00 | $621.00 | $621.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $460.00 / $460.00 / $460.00
| Facility | | $460.00 | $460.00 | $460.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $445.00 / $445.00 / $625.00
| Professional | | $445.00 | $445.00 | $625.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.66 / $404.26 / $481.05
| Professional | | $323.66 | $404.26 | $481.05 |