- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $514.66 / $514.66 / $593.84
| Professional | | $514.66 | $514.66 | $593.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $494.25 / $494.25 / $775.15
| Facility | | $494.25 | $494.25 | $775.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.80 / $494.25 / $526.90
| Professional | | $360.80 | $494.25 | $526.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $494.25 / $494.25 / $775.15
| Facility | | $494.25 | $494.25 | $775.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.80 / $494.25 / $526.90
| Professional | | $360.80 | $494.25 | $526.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.31 / $624.73 / $1,219.22
| Professional | | $358.31 | $624.73 | $1,219.22 |