- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $484.70 / $484.70 / $487.04
| Professional | | $484.70 | $484.70 | $487.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $547.67 / $647.54 / $655.86
| Professional | | $547.67 | $647.54 | $655.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $670.88 / $677.58 / $852.01
| Professional | | $670.88 | $677.58 | $852.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $484.70 / $487.04 / $583.91
| Facility | | $484.70 | $487.04 | $583.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.69 / $233.36 / $2,931.93
| Professional | | $184.69 | $233.36 | $2,931.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.53 / $230.54 / $466.72
| Professional | | $173.53 | $230.54 | $466.72 |