- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.20 / $260.20 / $260.20
| Professional | | $260.20 | $260.20 | $260.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $788.74 / $788.74 / $788.74
| Facility | | $788.74 | $788.74 | $788.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.10 / $260.20 / $260.20
| Professional | | $255.10 | $260.20 | $260.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $260.20 / $260.20 / $260.20
| Facility | | $260.20 | $260.20 | $260.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.20 / $260.20 / $260.20
| Professional | | $260.20 | $260.20 | $260.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.20 / $260.20 / $311.75
| Professional | | $260.20 | $260.20 | $311.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.20 / $260.20 / $260.20
| Professional | | $260.20 | $260.20 | $260.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.10 / $255.10 / $382.65
| Professional | | $255.10 | $255.10 | $382.65 |