- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.25 / $340.25 / $340.25
| Professional | | $340.25 | $340.25 | $340.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $530.01 / $530.01 / $530.01
| Facility | | $530.01 | $530.01 | $530.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.01 / $530.01 / $530.01
| Professional | | $530.01 | $530.01 | $530.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $530.01 / $530.01 / $530.01
| Facility | | $530.01 | $530.01 | $530.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.01 / $596.73 / $702.07
| Professional | | $530.01 | $596.73 | $702.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $600.00 / $600.00 / $600.00
| Facility | | $600.00 | $600.00 | $600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.92 / $549.27 / $662.90
| Professional | | $501.92 | $549.27 | $662.90 |