- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.58 / $585.58 / $585.58
| Professional | | $585.58 | $585.58 | $585.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $738.34 / $738.34 / $738.34
| Facility | | $738.34 | $738.34 | $738.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.22 / $731.53 / $738.34
| Professional | | $585.22 | $731.53 | $738.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $738.34 / $738.34 / $738.34
| Facility | | $738.34 | $738.34 | $738.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $458.28 / $458.28 / $738.34
| Professional | | $458.28 | $458.28 | $738.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.86 / $213.86 / $509.20
| Professional | | $213.86 | $213.86 | $509.20 |