- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $523.79 / $732.60 / $732.60
| Professional | | $523.79 | $732.60 | $732.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $560.05 / $748.80 / $748.80
| Professional | | $560.05 | $748.80 | $748.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $568.02 / $568.02 / $633.14
| Facility | | $568.02 | $568.02 | $633.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.58 / $568.02 / $778.09
| Professional | | $59.58 | $568.02 | $778.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $523.79 / $693.34 / $732.60
| Professional | | $523.79 | $693.34 | $732.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.80 / $615.38 / $1,340.04
| Professional | | $341.80 | $615.38 | $1,340.04 |