- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.39 / $225.39 / $225.39
| Professional | | $225.39 | $225.39 | $225.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,147.72 / $1,147.72 / $1,147.72
| Facility | | $1,147.72 | $1,147.72 | $1,147.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.05 / $317.58 / $919.81
| Professional | | $242.05 | $317.58 | $919.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.05 / $317.58 / $919.81
| Professional | | $242.05 | $317.58 | $919.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.35 / $299.19 / $502.35
| Professional | | $189.35 | $299.19 | $502.35 |