- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.93 / $748.93 / $748.93
| Professional | | $748.93 | $748.93 | $748.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,773.00 / $1,773.00 / $1,773.00
| Professional | | $1,773.00 | $1,773.00 | $1,773.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $400.00 / $400.00 / $400.00
| Facility | | $400.00 | $400.00 | $400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $413.66 / $413.66 / $413.66
| Professional | | $413.66 | $413.66 | $413.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $400.00 / $400.00 / $400.00
| Facility | | $400.00 | $400.00 | $400.00 |