- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.55 / $2,515.58 / $2,515.58
| Professional | | $343.55 | $2,515.58 | $2,515.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $643.82 / $643.82 / $643.82
| Professional | | $643.82 | $643.82 | $643.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $408.60 / $692.23 / $692.23
| Facility | | $408.60 | $692.23 | $692.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.60 / $562.92 / $692.23
| Professional | | $408.60 | $562.92 | $692.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $364.57 / $659.27 / $692.23
| Facility | | $364.57 | $659.27 | $692.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.60 / $519.54 / $692.74
| Professional | | $408.60 | $519.54 | $692.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.85 / $326.23 / $499.22
| Professional | | $294.85 | $326.23 | $499.22 |