- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $576.04 / $576.04 / $664.67
| Professional | | $576.04 | $576.04 | $664.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $867.63 / $944.53 / $944.53
| Facility | | $867.63 | $944.53 | $944.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $673.12 / $689.51 / $1,006.92
| Professional | | $673.12 | $689.51 | $1,006.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $867.63 / $944.53 / $944.53
| Facility | | $867.63 | $944.53 | $944.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $673.12 / $944.53 / $1,006.92
| Professional | | $673.12 | $944.53 | $1,006.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $392.62 / $699.27 / $1,364.67
| Professional | | $392.62 | $699.27 | $1,364.67 |