- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $475.00 / $500.00 / $1,151.54
| Professional | | $475.00 | $500.00 | $1,151.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.50 / $64.50 / $64.50
| Professional | | $64.50 | $64.50 | $64.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.19 / $263.19 / $263.19
| Facility | | $263.19 | $263.19 | $263.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.50 / $64.50 / $64.50
| Professional | | $64.50 | $64.50 | $64.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.19 / $263.19 / $263.19
| Facility | | $263.19 | $263.19 | $263.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.50 / $64.50 / $64.50
| Professional | | $64.50 | $64.50 | $64.50 |