- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $302.00 / $302.00
| Professional | | $302.00 | $302.00 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $309.03 / $524.81
| Facility | | $204.17 | $309.03 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $275.42 / $588.84
| Professional | | $213.80 | $275.42 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $954.99 / $954.99
| Facility | | $954.99 | $954.99 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,071.52
| Professional | | $1,000.00 | $1,000.00 | $1,071.52 |