- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.96 / $232.96 / $300.35
| Professional | | $232.96 | $232.96 | $300.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $681.46 / $681.46 / $681.46
| Professional | | $681.46 | $681.46 | $681.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.80 / $205.31 / $406.29
| Professional | | $190.80 | $205.31 | $406.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $232.96 / $260.92 / $413.74
| Facility | | $232.96 | $260.92 | $413.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $390.34 / $415.03 / $440.29
| Professional | | $390.34 | $415.03 | $440.29 |