- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.93 / $82.93 / $1,504.62
| Professional | | $82.93 | $82.93 | $1,504.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $391.66 / $391.66 / $391.66
| Facility | | $391.66 | $391.66 | $391.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.45 / $525.45 / $525.45
| Professional | | $525.45 | $525.45 | $525.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $391.66 / $391.66 / $391.66
| Facility | | $391.66 | $391.66 | $391.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.00 / $110.00 / $525.45
| Professional | | $110.00 | $110.00 | $525.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.21 / $234.00 / $540.63
| Professional | | $102.21 | $234.00 | $540.63 |