- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $560.98 / $619.61 / $805.27
| Professional | | $560.98 | $619.61 | $805.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.03 / $109.03 / $109.03
| Facility | | $109.03 | $109.03 | $109.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.73 / $80.73 / $80.73
| Professional | | $80.73 | $80.73 | $80.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $746.73 / $746.73 / $746.73
| Facility | | $746.73 | $746.73 | $746.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.92 / $746.73 / $746.73
| Professional | | $85.92 | $746.73 | $746.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.12 / $426.40 / $682.11
| Professional | | $341.12 | $426.40 | $682.11 |