- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $595.28 / $797.25 / $797.25
| Professional | | $595.28 | $797.25 | $797.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $344.45 / $344.45 / $344.45
| Facility | | $344.45 | $344.45 | $344.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $292.77 / $344.45 / $354.78
| Professional | | $292.77 | $344.45 | $354.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $344.45 / $344.45 / $344.45
| Facility | | $344.45 | $344.45 | $344.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $344.45 / $344.45 / $354.78
| Professional | | $344.45 | $344.45 | $354.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $400.45 / $667.43 / $1,001.13
| Professional | | $400.45 | $667.43 | $1,001.13 |