- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $730.71 / $730.71 / $843.13
| Professional | | $730.71 | $730.71 | $843.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $832.50 / $832.50 / $1,100.56
| Facility | | $832.50 | $832.50 | $1,100.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $607.73 / $832.50 / $857.48
| Professional | | $607.73 | $832.50 | $857.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $832.50 / $832.50 / $1,100.56
| Facility | | $832.50 | $832.50 | $1,100.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $607.73 / $832.50 / $857.48
| Professional | | $607.73 | $832.50 | $857.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $603.52 / $1,125.30 / $1,731.06
| Professional | | $603.52 | $1,125.30 | $1,731.06 |