- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.21 / $477.21 / $477.21
| Professional | | $477.21 | $477.21 | $477.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $516.39 / $516.39 / $516.39
| Facility | | $516.39 | $516.39 | $516.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $516.39 / $516.39 / $516.39
| Professional | | $516.39 | $516.39 | $516.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $516.39 / $516.39 / $516.39
| Facility | | $516.39 | $516.39 | $516.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.52 / $320.52 / $516.39
| Professional | | $320.52 | $320.52 | $516.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.57 / $149.57 / $356.13
| Professional | | $149.57 | $149.57 | $356.13 |