- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.91 / $327.91 / $378.35
| Professional | | $327.91 | $327.91 | $378.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $493.87 / $528.47 / $528.47
| Facility | | $493.87 | $528.47 | $528.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $385.78 / $502.79 / $563.38
| Professional | | $385.78 | $502.79 | $563.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $493.87 / $528.47 / $528.47
| Facility | | $493.87 | $528.47 | $528.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $385.78 / $528.47 / $563.38
| Professional | | $385.78 | $528.47 | $563.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.48 / $477.94 / $776.80
| Professional | | $223.48 | $477.94 | $776.80 |