- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $489.78 / $630.96
| Professional | | $354.81 | $489.78 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $645.65 / $645.65
| Facility | | $602.56 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $478.63 / $645.65
| Professional | | $478.63 | $478.63 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $812.83 / $1,071.52
| Professional | | $645.65 | $812.83 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $436.52 / $645.65
| Facility | | $363.08 | $436.52 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $616.60 / $1,737.80
| Professional | | $288.40 | $616.60 | $1,737.80 |