- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $511.96 / $511.96 / $639.95
| Professional | | $511.96 | $511.96 | $639.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,340.15 / $1,340.15 / $1,340.15
| Facility | | $1,340.15 | $1,340.15 | $1,340.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $470.00 / $1,344.06 / $1,344.06
| Professional | | $470.00 | $1,344.06 | $1,344.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $274.20 / $274.20 / $558.63
| Facility | | $274.20 | $274.20 | $558.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.20 / $458.43 / $558.63
| Professional | | $274.20 | $458.43 | $558.63 |