- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $660.69
| Professional | | $549.54 | $549.54 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $125.89 / $549.54
| Professional | | $125.89 | $125.89 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $549.54
| Facility | | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $549.54
| Professional | | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $562.34
| Professional | | $549.54 | $549.54 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $1,819.70
| Professional | | $549.54 | $549.54 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $549.54 / $2,691.53
| Professional | | $125.89 | $549.54 | $2,691.53 |