- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.02 / $317.02 / $365.81
| Professional | | $317.02 | $317.02 | $365.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $364.44 / $364.44 / $477.50
| Facility | | $364.44 | $364.44 | $477.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.04 / $364.44 / $388.52
| Professional | | $266.04 | $364.44 | $388.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $364.44 / $364.44 / $477.50
| Facility | | $364.44 | $364.44 | $477.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.04 / $364.44 / $388.52
| Professional | | $266.04 | $364.44 | $388.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.08 / $388.75 / $751.05
| Professional | | $216.08 | $388.75 | $751.05 |