- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.04 / $285.04 / $328.90
| Professional | | $285.04 | $285.04 | $328.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $429.32 / $503.81 / $503.81
| Facility | | $429.32 | $503.81 | $503.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.71 / $367.78 / $367.78
| Professional | | $363.71 | $367.78 | $367.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $429.32 / $503.81 / $503.81
| Facility | | $429.32 | $503.81 | $503.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.71 / $367.78 / $367.78
| Professional | | $363.71 | $367.78 | $367.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $388.77 / $388.77 / $388.77
| Facility | | $388.77 | $388.77 | $388.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.27 / $438.97 / $675.27
| Professional | | $194.27 | $438.97 | $675.27 |