- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.89 / $352.96 / $513.54
| Professional | | $245.89 | $352.96 | $513.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.10 / $616.10 / $616.10
| Professional | | $616.10 | $616.10 | $616.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.77 / $330.77 / $396.27
| Facility | | $330.77 | $330.77 | $396.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.97 / $330.77 / $506.25
| Professional | | $35.97 | $330.77 | $506.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.59 / $249.88 / $558.41
| Professional | | $166.59 | $249.88 | $558.41 |