- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.44 / $702.75 / $878.44
| Professional | | $226.44 | $702.75 | $878.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $287.11 / $444.29 / $724.54
| Facility | | $287.11 | $444.29 | $724.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.00 / $1,200.29 / $1,434.72
| Professional | | $265.00 | $1,200.29 | $1,434.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $462.00 / $462.00 / $462.00
| Facility | | $462.00 | $462.00 | $462.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $332.00 / $462.00 / $642.40
| Professional | | $332.00 | $462.00 | $642.40 |