- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.85 / $261.85 / $261.85
| Professional | | $261.85 | $261.85 | $261.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,339.72 / $1,339.72 / $1,339.72
| Facility | | $1,339.72 | $1,339.72 | $1,339.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.70 / $301.13 / $818.78
| Professional | | $265.70 | $301.13 | $818.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.70 / $301.13 / $818.78
| Professional | | $265.70 | $301.13 | $818.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.72 / $295.86 / $437.84
| Professional | | $222.72 | $295.86 | $437.84 |