- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $397.05 / $531.76 / $531.76
| Professional | | $397.05 | $531.76 | $531.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $458.33 / $458.33 / $458.33
| Facility | | $458.33 | $458.33 | $458.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.58 / $458.33 / $472.08
| Professional | | $389.58 | $458.33 | $472.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $458.33 / $458.33 / $458.33
| Facility | | $458.33 | $458.33 | $458.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $458.32 / $458.33 / $472.08
| Professional | | $458.32 | $458.33 | $472.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.18 / $784.90 / $1,028.44
| Professional | | $121.18 | $784.90 | $1,028.44 |