- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $352.51 / $380.43 / $404.86
| Professional | | $352.51 | $380.43 | $404.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $411.52 / $411.52 / $411.52
| Facility | | $411.52 | $411.52 | $411.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.01 / $411.52 / $411.52
| Professional | | $349.01 | $411.52 | $411.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $349.02 / $411.52 / $501.05
| Facility | | $349.02 | $411.52 | $501.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $378.65 / $378.65 / $500.00
| Professional | | $378.65 | $378.65 | $500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.02 / $349.02 / $349.02
| Professional | | $349.02 | $349.02 | $349.02 |