- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.72 / $262.72 / $314.77
| Professional | | $262.72 | $262.72 | $314.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Professional | | $150.00 | $150.00 | $150.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.54 / $120.70 / $123.43
| Facility | | $83.54 | $120.70 | $123.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.03 / $120.03 / $120.03
| Professional | | $120.03 | $120.03 | $120.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.96 / $120.70 / $127.71
| Facility | | $85.96 | $120.70 | $127.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.03 / $120.03 / $120.03
| Professional | | $120.03 | $120.03 | $120.03 |