- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $478.63 / $602.56
| Professional | | $478.63 | $478.63 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $524.81 / $602.56
| Professional | | $151.36 | $524.81 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $436.52 / $6,606.93
| Facility | | $389.05 | $436.52 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $549.54 / $1,479.11
| Professional | | $331.13 | $549.54 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $416.87 / $416.87
| Professional | | $416.87 | $416.87 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.03 / $416.87 / $501.19
| Professional | | $6.03 | $416.87 | $501.19 |