- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $401.46 / $401.46 / $463.22
| Professional | | $401.46 | $401.46 | $463.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $402.56 / $402.56 / $604.66
| Facility | | $402.56 | $402.56 | $604.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.87 / $402.56 / $414.64
| Professional | | $293.87 | $402.56 | $414.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $402.56 / $402.56 / $604.66
| Facility | | $402.56 | $402.56 | $604.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.87 / $402.56 / $414.64
| Professional | | $293.87 | $402.56 | $414.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.56 / $484.26 / $951.06
| Professional | | $284.56 | $484.26 | $951.06 |