- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.50 / $617.01 / $884.79
| Professional | | $155.50 | $617.01 | $884.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $265.52 / $265.52 / $265.52
| Facility | | $265.52 | $265.52 | $265.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.39 / $265.52 / $1,075.58
| Professional | | $227.39 | $265.52 | $1,075.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $265.52 / $265.52 / $265.52
| Facility | | $265.52 | $265.52 | $265.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.85 / $545.74 / $1,075.58
| Professional | | $173.85 | $545.74 | $1,075.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,067.56 / $1,250.52 / $1,593.79
| Professional | | $1,067.56 | $1,250.52 | $1,593.79 |