- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.32 / $578.04 / $578.04
| Professional | | $326.32 | $578.04 | $578.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.78 / $562.78 / $573.88
| Facility | | $562.78 | $562.78 | $573.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $603.08 / $603.08 / $780.25
| Facility | | $603.08 | $603.08 | $780.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $603.08 / $603.08 / $780.25
| Facility | | $603.08 | $603.08 | $780.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.01 / $303.01 / $303.01
| Professional | | $303.01 | $303.01 | $303.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.62 / $652.64 / $1,077.04
| Professional | | $203.62 | $652.64 | $1,077.04 |