- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $342.68 / $342.68 / $342.68
| Professional | | $342.68 | $342.68 | $342.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.36 / $83.36 / $83.36
| Professional | | $83.36 | $83.36 | $83.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.77 / $330.77 / $330.77
| Facility | | $330.77 | $330.77 | $330.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.97 / $330.77 / $1,128.83
| Professional | | $35.97 | $330.77 | $1,128.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.38 / $330.77 / $676.26
| Facility | | $40.38 | $330.77 | $676.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.97 / $330.77 / $1,128.83
| Professional | | $35.97 | $330.77 | $1,128.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.88 / $249.88 / $325.45
| Professional | | $249.88 | $249.88 | $325.45 |