- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.20 / $678.78 / $736.87
| Professional | | $541.20 | $678.78 | $736.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $536.83 / $536.83 / $536.83
| Facility | | $536.83 | $536.83 | $536.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.31 / $536.83 / $536.83
| Professional | | $456.31 | $536.83 | $536.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $99,999.99 / $99,999.99 / $99,999.99
| Facility | | $99,999.99 | $99,999.99 | $99,999.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99,999.99 / $99,999.99 / $99,999.99
| Professional | | $99,999.99 | $99,999.99 | $99,999.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,051.47 / $1,051.47 / $1,051.47
| Professional | | $1,051.47 | $1,051.47 | $1,051.47 |