- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.58 / $340.58 / $360.04
| Professional | | $340.58 | $340.58 | $360.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $515.75 / $573.04 / $598.44
| Facility | | $515.75 | $573.04 | $598.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $644.66 / $644.66 / $644.66
| Professional | | $644.66 | $644.66 | $644.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $583.85 / $583.85 / $583.85
| Facility | | $583.85 | $583.85 | $583.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.35 / $291.92 / $701.74
| Professional | | $204.35 | $291.92 | $701.74 |