- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.17 / $324.70 / $350.37
| Professional | | $309.17 | $324.70 | $350.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $666.06 / $666.06 / $666.06
| Facility | | $666.06 | $666.06 | $666.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $566.15 / $566.15 / $666.06
| Professional | | $566.15 | $566.15 | $666.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,781.89 / $4,781.89 / $4,781.89
| Facility | | $4,781.89 | $4,781.89 | $4,781.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.40 / $401.57 / $564.55
| Professional | | $338.40 | $401.57 | $564.55 |