- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $574.95 / $574.95 / $574.95
| Professional | | $574.95 | $574.95 | $574.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $671.57 / $963.75 / $1,320.01
| Facility | | $671.57 | $963.75 | $1,320.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.00 / $6.00 / $1,971.10
| Professional | | $6.00 | $6.00 | $1,971.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $733.96 / $2,481.09 / $5,261.45
| Facility | | $733.96 | $2,481.09 | $5,261.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,273.00 / $4,273.00 / $4,273.00
| Professional | | $4,273.00 | $4,273.00 | $4,273.00 |