- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.14 / $283.14 / $283.14
| Professional | | $283.14 | $283.14 | $283.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $441.15 / $441.15 / $441.15
| Facility | | $441.15 | $441.15 | $441.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $441.15 / $441.15 / $441.15
| Professional | | $441.15 | $441.15 | $441.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $441.15 / $441.15 / $441.15
| Facility | | $441.15 | $441.15 | $441.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $441.15 / $496.75 / $584.44
| Professional | | $441.15 | $496.75 | $584.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.91 / $474.00 / $730.75
| Professional | | $402.91 | $474.00 | $730.75 |