- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $413.14 / $413.14 / $476.70
| Professional | | $413.14 | $413.14 | $476.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $496.34 / $496.34 / $622.26
| Facility | | $496.34 | $496.34 | $622.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.33 / $362.33 / $479.50
| Professional | | $362.33 | $362.33 | $479.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $496.34 / $496.34 / $622.26
| Facility | | $496.34 | $496.34 | $622.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.33 / $362.33 / $479.50
| Professional | | $362.33 | $362.33 | $479.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.36 / $636.24 / $978.73
| Professional | | $381.36 | $636.24 | $978.73 |