- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.82 / $364.82 / $437.09
| Professional | | $364.82 | $364.82 | $437.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.00 / $170.00 / $178.00
| Professional | | $170.00 | $170.00 | $178.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.86 / $199.68 / $261.02
| Facility | | $142.86 | $199.68 | $261.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.47 / $203.47 / $203.47
| Professional | | $203.47 | $203.47 | $203.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.66 / $197.79 / $261.02
| Facility | | $131.66 | $197.79 | $261.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.47 / $203.47 / $203.47
| Professional | | $203.47 | $203.47 | $203.47 |