- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.95 / $81.50 / $540.42
| Professional | | $56.95 | $81.50 | $540.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $728.23 / $728.23 / $728.23
| Facility | | $728.23 | $728.23 | $728.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $728.23 / $728.23 / $785.24
| Professional | | $728.23 | $728.23 | $785.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $81.50 / $728.23 / $728.23
| Facility | | $81.50 | $728.23 | $728.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $728.23 / $728.23 / $785.24
| Professional | | $728.23 | $728.23 | $785.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,438.66 / $1,438.66 / $1,438.66
| Professional | | $1,438.66 | $1,438.66 | $1,438.66 |