- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $407.38 / $446.68
| Professional | | $363.08 | $407.38 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $104.71
| Professional | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $407.38 / $812.83
| Facility | | $407.38 | $407.38 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $407.38 / $446.68
| Professional | | $407.38 | $407.38 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $407.38 / $660.69
| Facility | | $407.38 | $407.38 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.48 / $35.48 / $100.00
| Professional | | $35.48 | $35.48 | $100.00 |