- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.54 / $518.54 / $518.54
| Professional | | $518.54 | $518.54 | $518.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $653.82 / $653.82 / $653.82
| Facility | | $653.82 | $653.82 | $653.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $653.82 / $653.82 / $653.82
| Professional | | $653.82 | $653.82 | $653.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $653.82 / $653.82 / $653.82
| Facility | | $653.82 | $653.82 | $653.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $405.82 / $405.82 / $653.82
| Professional | | $405.82 | $405.82 | $653.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.38 / $189.38 / $450.91
| Professional | | $189.38 | $189.38 | $450.91 |