- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.34 / $212.34 / $212.34
| Professional | | $212.34 | $212.34 | $212.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.28 / $26.28 / $26.28
| Professional | | $26.28 | $26.28 | $26.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.34 / $212.34 / $212.34
| Facility | | $212.34 | $212.34 | $212.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.34 / $212.34 / $345.58
| Facility | | $212.34 | $212.34 | $345.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $58.40 / $70.00
| Professional | | $50.00 | $58.40 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.34 / $212.34 / $212.34
| Facility | | $212.34 | $212.34 | $212.34 |