- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.05 / $316.05 / $316.05
| Professional | | $316.05 | $316.05 | $316.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.50 / $398.50 / $398.50
| Facility | | $398.50 | $398.50 | $398.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.50 / $398.50 / $398.50
| Professional | | $398.50 | $398.50 | $398.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.50 / $398.50 / $398.50
| Facility | | $398.50 | $398.50 | $398.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.35 / $247.35 / $398.50
| Professional | | $247.35 | $247.35 | $398.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.54 / $103.54 / $246.52
| Professional | | $103.54 | $103.54 | $246.52 |