- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.43 / $327.43 / $390.48
| Professional | | $327.43 | $327.43 | $390.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.20 / $407.20 / $1,318.82
| Facility | | $407.20 | $407.20 | $1,318.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.67 / $407.20 / $473.37
| Professional | | $320.67 | $407.20 | $473.37 |
- 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
- $310.31 / $310.31 / $310.31
| Professional | | $310.31 | $310.31 | $310.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $327.43 / $390.48 / $585.72
| Facility | | $327.43 | $390.48 | $585.72 |