- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.34 / $328.34 / $2,736.67
| Professional | | $328.34 | $328.34 | $2,736.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.70 / $371.70 / $371.70
| Facility | | $371.70 | $371.70 | $371.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.75 / $326.94 / $544.90
| Facility | | $309.75 | $326.94 | $544.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.34 / $328.34 / $544.90
| Professional | | $328.34 | $328.34 | $544.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.75 / $326.94 / $544.90
| Facility | | $309.75 | $326.94 | $544.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.34 / $328.34 / $544.90
| Professional | | $328.34 | $328.34 | $544.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.34 / $348.04 / $1,275.22
| Professional | | $328.34 | $348.04 | $1,275.22 |