- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $517.50 / $517.50 / $517.50
| Professional | | $517.50 | $517.50 | $517.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $990.14 / $1,062.10 / $1,076.24
| Professional | | $990.14 | $1,062.10 | $1,076.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $516.50 / $516.50 / $516.50
| Professional | | $516.50 | $516.50 | $516.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $698.76 / $899.94 / $1,380.55
| Professional | | $698.76 | $899.94 | $1,380.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $517.50 / $517.50 / $538.40
| Professional | | $517.50 | $517.50 | $538.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.56 / $851.56 / $851.56
| Professional | | $851.56 | $851.56 | $851.56 |