- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.06 / $90.65 / $90.65
| Professional | | $80.06 | $90.65 | $90.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $355.73 / $355.73 / $355.73
| Facility | | $355.73 | $355.73 | $355.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $374.70 / $374.70 / $374.70
| Facility | | $374.70 | $374.70 | $374.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.25 / $140.25 / $140.25
| Professional | | $140.25 | $140.25 | $140.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $374.70 / $374.70 / $374.70
| Facility | | $374.70 | $374.70 | $374.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.25 / $140.25 / $140.25
| Professional | | $140.25 | $140.25 | $140.25 |