- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.67 / $253.36 / $253.36
| Professional | | $205.67 | $253.36 | $253.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $498.19 / $498.19 / $538.22
| Facility | | $498.19 | $498.19 | $538.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.36 / $253.36 / $253.36
| Professional | | $253.36 | $253.36 | $253.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.36 / $253.36 / $253.36
| Professional | | $253.36 | $253.36 | $253.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.39 / $248.39 / $745.17
| Professional | | $248.39 | $248.39 | $745.17 |