- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.64 / $617.17 / $682.20
| Professional | | $524.64 | $617.17 | $682.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $67.52 / $83.10 / $911.46
| Facility | | $67.52 | $83.10 | $911.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.52 / $72.70 / $981.58
| Professional | | $67.52 | $72.70 | $981.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $981.64 / $2,355.54 / $2,355.54
| Facility | | $981.64 | $2,355.54 | $2,355.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.42 / $2,355.54 / $2,550.52
| Professional | | $73.42 | $2,355.54 | $2,550.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $374.67 / $488.98 / $917.70
| Professional | | $374.67 | $488.98 | $917.70 |