- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.57 / $103.75 / $1,234.56
| Professional | | $58.57 | $103.75 | $1,234.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $321.36 / $321.36 / $321.36
| Facility | | $321.36 | $321.36 | $321.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.95 / $95.00 / $431.38
| Professional | | $39.95 | $95.00 | $431.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $321.36 / $321.36 / $321.36
| Facility | | $321.36 | $321.36 | $321.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.95 / $96.22 / $431.38
| Professional | | $39.95 | $96.22 | $431.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.64 / $117.14 / $443.60
| Professional | | $80.64 | $117.14 | $443.60 |