- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.36 / $461.36 / $461.36
| Professional | | $461.36 | $461.36 | $461.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $364.52 / $435.24 / $567.79
| Facility | | $364.52 | $435.24 | $567.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.52 / $461.36 / $461.36
| Professional | | $364.52 | $461.36 | $461.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $364.52 / $435.24 / $567.79
| Facility | | $364.52 | $435.24 | $567.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.52 / $461.36 / $478.76
| Professional | | $364.52 | $461.36 | $478.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.36 / $461.36 / $1,384.08
| Professional | | $461.36 | $461.36 | $1,384.08 |