- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $583.33 / $619.79 / $756.38
| Professional | | $583.33 | $619.79 | $756.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $66.98 / $502.33 / $873.55
| Facility | | $66.98 | $502.33 | $873.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.13 / $540.97 / $927.39
| Professional | | $72.13 | $540.97 | $927.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $670.25 / $670.25 / $1,567.75
| Facility | | $670.25 | $670.25 | $1,567.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $670.25 / $809.86 / $971.18
| Professional | | $670.25 | $809.86 | $971.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $546.96 / $659.31 / $1,292.77
| Professional | | $546.96 | $659.31 | $1,292.77 |