- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.44 / $341.00 / $448.40
| Professional | | $226.44 | $341.00 | $448.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $497.01 / $497.01 / $497.01
| Facility | | $497.01 | $497.01 | $497.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $497.01 / $497.01 / $497.01
| Professional | | $497.01 | $497.01 | $497.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.55 / $354.55 / $562.79
| Facility | | $354.55 | $354.55 | $562.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.37 / $354.55 / $465.35
| Professional | | $301.37 | $354.55 | $465.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.58 / $370.42 / $714.21
| Professional | | $181.58 | $370.42 | $714.21 |