- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.43 / $344.85 / $344.85
| Professional | | $336.43 | $344.85 | $344.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.00 / $500.00 / $500.00
| Professional | | $500.00 | $500.00 | $500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $306.10 / $306.10 / $306.10
| Facility | | $306.10 | $306.10 | $306.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.50 / $168.50 / $210.63
| Professional | | $168.50 | $168.50 | $210.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $751.07 / $751.07 / $751.07
| Professional | | $751.07 | $751.07 | $751.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.43 / $344.85 / $370.08
| Professional | | $336.43 | $344.85 | $370.08 |