- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $223.87 / $223.87
| Professional | | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.97 / $223.87 / $338.84
| Facility | | $181.97 | $223.87 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $251.19 / $338.84
| Professional | | $173.78 | $251.19 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $501.19
| Facility | | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $776.25 / $776.25
| Professional | | $776.25 | $776.25 | $776.25 |