- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.04 / $540.96 / $876.05
| Professional | | $356.04 | $540.96 | $876.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $96.00 / $376.92 / $628.08
| Facility | | $96.00 | $376.92 | $628.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.40 / $96.00 / $111.60
| Professional | | $80.40 | $96.00 | $111.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $542.08 / $542.08 / $876.05
| Facility | | $542.08 | $542.08 | $876.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.40 / $1,274.40 / $1,274.40
| Professional | | $1,274.40 | $1,274.40 | $1,274.40 |