- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $397.93 / $397.93 / $497.42
| Professional | | $397.93 | $397.93 | $497.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,340.15 / $1,340.15 / $1,340.15
| Facility | | $1,340.15 | $1,340.15 | $1,340.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $427.00 / $1,969.00 / $1,969.00
| Professional | | $427.00 | $1,969.00 | $1,969.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $240.54 / $240.54 / $517.62
| Facility | | $240.54 | $240.54 | $517.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.54 / $401.92 / $517.62
| Professional | | $240.54 | $401.92 | $517.62 |