- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $354.81 / $602.56
| Professional | | $288.40 | $354.81 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $234.42 / $234.42
| Professional | | $234.42 | $234.42 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $371.54 / $741.31
| Professional | | $194.98 | $371.54 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $630.96 / $630.96
| Facility | | $630.96 | $630.96 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $912.01
| Professional | | $912.01 | $912.01 | $912.01 |