- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $382.27 / $655.68 / $819.60
| Professional | | $382.27 | $655.68 | $819.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $766.64 / $766.64 / $766.64
| Facility | | $766.64 | $766.64 | $766.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.66 / $651.64 / $1,537.50
| Professional | | $85.66 | $651.64 | $1,537.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.45 / $479.26 / $5,600.27
| Facility | | $85.45 | $479.26 | $5,600.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.07 / $524.61 / $830.25
| Professional | | $350.07 | $524.61 | $830.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.07 / $525.10 / $727.46
| Professional | | $350.07 | $525.10 | $727.46 |