- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $616.60 / $616.60
| Professional | | $501.19 | $616.60 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.74 / $63.10 / $63.10
| Professional | | $40.74 | $63.10 | $63.10 |
- 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
- $295.12 / $346.74 / $346.74
| Professional | | $295.12 | $346.74 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $79.43 / $588.84 / $794.33
| Facility | | $79.43 | $588.84 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $630.96 / $1,047.13
| Professional | | $380.19 | $630.96 | $1,047.13 |