- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.56 / $118.56 / $118.56
| Professional | | $118.56 | $118.56 | $118.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $654.75 / $654.75 / $654.75
| Facility | | $654.75 | $654.75 | $654.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.35 / $654.75 / $1,683.84
| Professional | | $44.35 | $654.75 | $1,683.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $48.90 / $654.75 / $1,129.86
| Facility | | $48.90 | $654.75 | $1,129.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.35 / $654.75 / $1,683.84
| Professional | | $44.35 | $654.75 | $1,683.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.51 / $397.78 / $662.97
| Professional | | $373.51 | $397.78 | $662.97 |