- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.90 / $201.90 / $534.90
| Professional | | $201.90 | $201.90 | $534.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $392.10 / $392.10 / $392.10
| Professional | | $392.10 | $392.10 | $392.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.77 / $330.77 / $346.29
| Facility | | $330.77 | $330.77 | $346.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.77 / $330.77 / $330.77
| Professional | | $330.77 | $330.77 | $330.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.88 / $300.41 / $368.68
| Professional | | $249.88 | $300.41 | $368.68 |