- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $678.78 / $678.78 / $678.78
| Professional | | $678.78 | $678.78 | $678.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $536.83 / $536.83 / $536.83
| Facility | | $536.83 | $536.83 | $536.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.31 / $536.83 / $536.83
| Professional | | $456.31 | $536.83 | $536.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,123.02 / $1,338.00 / $1,539.60
| Professional | | $1,123.02 | $1,338.00 | $1,539.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |