- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.30 / $777.01 / $777.02
| Facility | | $151.30 | $777.01 | $777.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $367.82 / $777.02 / $777.02
| Professional | | $367.82 | $777.02 | $777.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $482.06 / $482.06 / $482.06
| Professional | | $482.06 | $482.06 | $482.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.14 / $501.14 / $928.63
| Facility | | $501.14 | $501.14 | $928.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $365.83 / $501.14 / $813.15
| Professional | | $365.83 | $501.14 | $813.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.74 / $400.12 / $602.72
| Professional | | $266.74 | $400.12 | $602.72 |