- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $563.95 / $622.88 / $809.54
| Professional | | $563.95 | $622.88 | $809.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.62 / $109.62 / $109.62
| Facility | | $109.62 | $109.62 | $109.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.97 / $81.97 / $81.97
| Professional | | $81.97 | $81.97 | $81.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,013.42 / $2,355.54 / $2,355.54
| Facility | | $1,013.42 | $2,355.54 | $2,355.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.42 / $2,002.21 / $2,355.54
| Professional | | $73.42 | $2,002.21 | $2,355.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.45 / $390.60 / $732.62
| Professional | | $291.45 | $390.60 | $732.62 |