- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.77 / $486.62 / $570.92
| Professional | | $268.77 | $486.62 | $570.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,361.01 / $1,838.21 / $2,176.21
| Facility | | $1,361.01 | $1,838.21 | $2,176.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $628.75 / $628.75 / $870.50
| Professional | | $628.75 | $628.75 | $870.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $510.00 / $516.29 / $556.80
| Facility | | $510.00 | $516.29 | $556.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $372.30 / $510.00 / $516.29
| Professional | | $372.30 | $510.00 | $516.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $367.01 / $480.24 / $800.40
| Professional | | $367.01 | $480.24 | $800.40 |