- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $548.57 / $548.57 / $548.57
| Professional | | $548.57 | $548.57 | $548.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $734.36 / $734.36 / $734.36
| Professional | | $734.36 | $734.36 | $734.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.49 / $324.76 / $734.36
| Professional | | $183.49 | $324.76 | $734.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.76 / $423.36 / $734.36
| Professional | | $324.76 | $423.36 | $734.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.68 / $270.55 / $901.35
| Professional | | $194.68 | $270.55 | $901.35 |