- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $372.00 / $421.60 / $541.09
| Facility | | $372.00 | $421.60 | $541.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.09 / $541.09 / $541.09
| Professional | | $541.09 | $541.09 | $541.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $424.94 / $509.53 / $563.64
| Professional | | $424.94 | $509.53 | $563.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $496.00 / $541.09 / $631.27
| Professional | | $496.00 | $541.09 | $631.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $450.91 / $541.09 / $676.37
| Professional | | $450.91 | $541.09 | $676.37 |