- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $386.56 / $386.56 / $446.03
| Professional | | $386.56 | $386.56 | $446.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $525.23 / $525.23 / $525.23
| Facility | | $525.23 | $525.23 | $525.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $383.42 / $383.42 / $559.92
| Professional | | $383.42 | $383.42 | $559.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $525.23 / $525.23 / $525.23
| Facility | | $525.23 | $525.23 | $525.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $383.42 / $525.23 / $559.92
| Professional | | $383.42 | $525.23 | $559.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.45 / $545.00 / $915.77
| Professional | | $263.45 | $545.00 | $915.77 |