- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.76 / $246.76 / $246.76
| Professional | | $246.76 | $246.76 | $246.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $360.48 / $459.70 / $590.41
| Facility | | $360.48 | $459.70 | $590.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $232.89 / $232.89 / $232.89
| Facility | | $232.89 | $232.89 | $232.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.51 / $198.51 / $198.51
| Professional | | $198.51 | $198.51 | $198.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.13 / $201.13 / $201.13
| Professional | | $201.13 | $201.13 | $201.13 |