- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.05 / $461.05 / $531.98
| Professional | | $461.05 | $461.05 | $531.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $511.94 / $511.94 / $694.40
| Facility | | $511.94 | $511.94 | $694.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.72 / $373.72 / $441.06
| Professional | | $373.72 | $373.72 | $441.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $511.94 / $511.94 / $694.40
| Facility | | $511.94 | $511.94 | $694.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.72 / $373.72 / $441.06
| Professional | | $373.72 | $373.72 | $441.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.22 / $559.65 / $1,092.22
| Professional | | $314.22 | $559.65 | $1,092.22 |