- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.90 / $580.27 / $671.99
| Professional | | $340.90 | $580.27 | $671.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,601.92 / $2,163.58 / $2,561.42
| Facility | | $1,601.92 | $2,163.58 | $2,561.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $629.03 / $740.04 / $1,024.58
| Professional | | $629.03 | $740.04 | $1,024.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $655.36 / $700.00 / $773.33
| Facility | | $655.36 | $700.00 | $773.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $511.00 / $700.00 / $773.33
| Professional | | $511.00 | $700.00 | $773.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $442.58 / $598.14 / $942.08
| Professional | | $442.58 | $598.14 | $942.08 |