- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.85 / $347.63 / $488.52
| Professional | | $311.85 | $347.63 | $488.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.67 / $200.00 / $315.35
| Facility | | $116.67 | $200.00 | $315.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.13 / $228.13 / $315.35
| Professional | | $228.13 | $228.13 | $315.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.85 / $198.26 / $315.35
| Facility | | $157.85 | $198.26 | $315.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.85 / $259.85 / $315.35
| Professional | | $157.85 | $259.85 | $315.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.00 / $10.00 / $10.00
| Professional | | $10.00 | $10.00 | $10.00 |