- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.78 / $232.78 / $1,704.98
| Professional | | $232.78 | $232.78 | $1,704.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $376.09 / $376.09 / $376.09
| Facility | | $376.09 | $376.09 | $376.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.68 / $376.09 / $661.50
| Professional | | $319.68 | $376.09 | $661.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.48 / $381.02 / $551.56
| Professional | | $262.48 | $381.02 | $551.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.78 / $286.08 / $517.29
| Professional | | $232.78 | $286.08 | $517.29 |