- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.77 / $236.77 / $236.77
| Professional | | $236.77 | $236.77 | $236.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $472.17 / $472.17 / $561.25
| Facility | | $472.17 | $472.17 | $561.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $472.17 / $472.17 / $472.17
| Professional | | $472.17 | $472.17 | $472.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $472.17 / $472.17 / $561.25
| Facility | | $472.17 | $472.17 | $561.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.96 / $472.17 / $502.32
| Professional | | $426.96 | $472.17 | $502.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.95 / $213.13 / $430.98
| Professional | | $206.95 | $213.13 | $430.98 |