- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $476.67 / $638.40 / $638.40
| Professional | | $476.67 | $638.40 | $638.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $428.20 / $428.20 / $428.20
| Facility | | $428.20 | $428.20 | $428.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.97 / $428.20 / $441.05
| Professional | | $363.97 | $428.20 | $441.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $428.20 / $428.20 / $428.20
| Facility | | $428.20 | $428.20 | $428.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $428.20 / $428.20 / $441.05
| Professional | | $428.20 | $428.20 | $441.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.70 / $534.62 / $801.78
| Professional | | $320.70 | $534.62 | $801.78 |