- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.70 / $275.70 / $328.28
| Professional | | $275.70 | $275.70 | $328.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.83 / $357.47 / $357.47
| Professional | | $303.83 | $357.47 | $357.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $573.75 / $573.75 / $573.75
| Facility | | $573.75 | $573.75 | $573.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $226.63 / $226.63 / $226.63
| Facility | | $226.63 | $226.63 | $226.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.64 / $192.64 / $226.63
| Professional | | $192.64 | $192.64 | $226.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,193.00 / $1,193.00 / $1,193.00
| Professional | | $1,193.00 | $1,193.00 | $1,193.00 |