- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.44 / $402.44 / $464.36
| Professional | | $402.44 | $402.44 | $464.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $420.01 / $420.01 / $606.14
| Facility | | $420.01 | $420.01 | $606.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.61 / $420.01 / $447.75
| Professional | | $306.61 | $420.01 | $447.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $420.01 / $420.01 / $606.14
| Facility | | $420.01 | $420.01 | $606.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.61 / $420.01 / $447.75
| Professional | | $306.61 | $420.01 | $447.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.29 / $505.25 / $953.38
| Professional | | $274.29 | $505.25 | $953.38 |