- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $511.16 / $511.16 / $511.16
| Professional | | $511.16 | $511.16 | $511.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $654.00 / $654.75 / $654.75
| Facility | | $654.00 | $654.75 | $654.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.35 / $654.75 / $674.39
| Professional | | $44.35 | $654.75 | $674.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.63 / $292.08 / $463.06
| Professional | | $165.63 | $292.08 | $463.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.67 / $448.08 / $843.63
| Professional | | $381.67 | $448.08 | $843.63 |