- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $430.86 / $430.86 / $497.15
| Professional | | $430.86 | $430.86 | $497.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $472.30 / $472.30 / $648.92
| Facility | | $472.30 | $472.30 | $648.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $344.78 / $472.30 / $503.49
| Professional | | $344.78 | $472.30 | $503.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $472.30 / $472.30 / $648.92
| Facility | | $472.30 | $472.30 | $648.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $344.78 / $472.30 / $503.49
| Professional | | $344.78 | $472.30 | $503.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $305.39 / $663.52 / $1,020.70
| Professional | | $305.39 | $663.52 | $1,020.70 |