- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.22 / $363.31 / $423.97
| Professional | | $343.22 | $363.31 | $423.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $593.10 / $593.10 / $593.10
| Professional | | $593.10 | $593.10 | $593.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $593.10 / $593.10 / $593.10
| Facility | | $593.10 | $593.10 | $593.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $532.27 / $593.10 / $593.10
| Professional | | $532.27 | $593.10 | $593.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $593.10 / $593.10 / $593.10
| Facility | | $593.10 | $593.10 | $593.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.94 / $532.27 / $787.50
| Professional | | $363.94 | $532.27 | $787.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $583.45 / $673.21 / $1,039.69
| Professional | | $583.45 | $673.21 | $1,039.69 |