- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $514.16 / $532.35 / $678.94
| Professional | | $514.16 | $532.35 | $678.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $700.00 / $700.00 / $773.33
| Facility | | $700.00 | $700.00 | $773.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $511.00 / $511.00 / $773.33
| Professional | | $511.00 | $511.00 | $773.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $873.45 / $873.45 / $873.45
| Professional | | $873.45 | $873.45 | $873.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $480.00 / $480.00 / $480.00
| Facility | | $480.00 | $480.00 | $480.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $465.52 / $645.32 / $972.08
| Professional | | $465.52 | $645.32 | $972.08 |