- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $406.02 / $429.48 / $441.16
| Professional | | $406.02 | $429.48 | $441.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.76 / $88.76 / $88.76
| Professional | | $88.76 | $88.76 | $88.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $429.48 / $433.31 / $721.53
| Facility | | $429.48 | $433.31 | $721.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |