- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $570.42 / $570.42 / $732.88
| Professional | | $570.42 | $570.42 | $732.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $640.00 / $800.00 / $1,008.59
| Professional | | $640.00 | $800.00 | $1,008.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.87 / $746.73 / $746.73
| Facility | | $562.87 | $746.73 | $746.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.22 / $746.73 / $746.73
| Professional | | $90.22 | $746.73 | $746.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $332.82 / $570.42 / $732.88
| Facility | | $332.82 | $570.42 | $732.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.00 / $575.00 / $575.00
| Professional | | $575.00 | $575.00 | $575.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $312.49 / $429.62 / $596.96
| Professional | | $312.49 | $429.62 | $596.96 |