- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $546.49 / $546.49 / $546.49
| Professional | | $546.49 | $546.49 | $546.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.54 / $540.54 / $540.54
| Facility | | $540.54 | $540.54 | $540.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.78 / $370.87 / $514.67
| Professional | | $223.78 | $370.87 | $514.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.54 / $540.54 / $540.54
| Facility | | $540.54 | $540.54 | $540.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.78 / $370.87 / $514.67
| Professional | | $223.78 | $370.87 | $514.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.78 / $352.80 / $677.96
| Professional | | $193.78 | $352.80 | $677.96 |