- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.13 / $276.87 / $342.66
| Professional | | $274.13 | $276.87 | $342.66 |
- 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
- $470.93 / $470.93 / $470.93
| Facility | | $470.93 | $470.93 | $470.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.37 / $398.37 / $398.37
| Professional | | $398.37 | $398.37 | $398.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.37 / $398.37 / $398.37
| Professional | | $398.37 | $398.37 | $398.37 |