- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.64 / $252.64 / $252.64
| Professional | | $252.64 | $252.64 | $252.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.94 / $31.94 / $31.94
| Professional | | $31.94 | $31.94 | $31.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $252.64 / $252.64 / $252.64
| Facility | | $252.64 | $252.64 | $252.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $252.64 / $252.64 / $802.29
| Facility | | $252.64 | $252.64 | $802.29 |
- 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
- $252.64 / $252.64 / $252.64
| Facility | | $252.64 | $252.64 | $252.64 |