- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.36 / $308.36 / $355.80
| Professional | | $308.36 | $308.36 | $355.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $427.13 / $427.13 / $464.43
| Facility | | $427.13 | $427.13 | $464.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.80 / $427.13 / $439.94
| Professional | | $311.80 | $427.13 | $439.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $427.13 / $427.13 / $464.43
| Facility | | $427.13 | $427.13 | $464.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.80 / $427.13 / $439.94
| Professional | | $311.80 | $427.13 | $439.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.17 / $454.00 / $730.50
| Professional | | $210.17 | $454.00 | $730.50 |