- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.62 / $205.62 / $2,167.12
| Professional | | $205.62 | $205.62 | $2,167.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $461.38 / $461.38 / $461.38
| Facility | | $461.38 | $461.38 | $461.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $392.17 / $461.38 / $1,088.44
| Professional | | $392.17 | $461.38 | $1,088.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $339.95 / $493.48 / $715.45
| Professional | | $339.95 | $493.48 | $715.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.62 / $318.51 / $456.94
| Professional | | $205.62 | $318.51 | $456.94 |