- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.25 / $375.25 / $375.25
| Facility | | $375.25 | $375.25 | $375.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $370.75 / $375.25 / $375.25
| Professional | | $370.75 | $375.25 | $375.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $469.06 / $582.00 / $1,201.00
| Professional | | $469.06 | $582.00 | $1,201.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $750.20 / $750.20 / $750.20
| Facility | | $750.20 | $750.20 | $750.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.26 / $610.36 / $806.96
| Professional | | $177.26 | $610.36 | $806.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.61 / $157.61 / $375.25
| Professional | | $157.61 | $157.61 | $375.25 |