- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $342.82 / $342.82 / $395.57
| Professional | | $342.82 | $342.82 | $395.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $502.54 / $502.54 / $516.34
| Facility | | $502.54 | $502.54 | $516.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $427.16 / $437.70 / $517.62
| Professional | | $427.16 | $437.70 | $517.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $502.54 / $502.54 / $516.34
| Facility | | $502.54 | $502.54 | $516.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $427.16 / $502.54 / $517.62
| Professional | | $427.16 | $502.54 | $517.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.65 / $527.95 / $812.15
| Professional | | $233.65 | $527.95 | $812.15 |