- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $371.54 / $741.31
| Professional | | $309.03 | $371.54 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $239.88 / $239.88
| Professional | | $154.88 | $239.88 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $102.33 / $204.17
| Professional | | $102.33 | $102.33 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $346.74
| Facility | | $346.74 | $346.74 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $602.56 / $831.76
| Professional | | $89.13 | $602.56 | $831.76 |