- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $292.44 / $292.44 / $365.55
| Professional | | $292.44 | $292.44 | $365.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $264.70 / $270.93 / $778.41
| Facility | | $264.70 | $270.93 | $778.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.00 / $1,012.00 / $1,012.00
| Professional | | $275.00 | $1,012.00 | $1,012.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $285.00 / $285.00 / $285.00
| Facility | | $285.00 | $285.00 | $285.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.35 / $272.99 / $329.00
| Professional | | $263.35 | $272.99 | $329.00 |