- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.54 / $668.13 / $2,469.17
| Professional | | $501.54 | $668.13 | $2,469.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $760.83 / $760.83 / $760.83
| Facility | | $760.83 | $760.83 | $760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $357.24 / $760.83 / $767.66
| Professional | | $357.24 | $760.83 | $767.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $376.63 / $499.53 / $760.83
| Facility | | $376.63 | $499.53 | $760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $454.52 / $757.58 / $983.50
| Professional | | $454.52 | $757.58 | $983.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $621.17 / $756.56 / $864.64
| Professional | | $621.17 | $756.56 | $864.64 |