- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $597.58 / $597.58 / $597.58
| Professional | | $597.58 | $597.58 | $597.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $875.46 / $875.46 / $875.46
| Facility | | $875.46 | $875.46 | $875.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.13 / $744.14 / $875.46
| Professional | | $283.13 | $744.14 | $875.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $453.67 / $610.13 / $875.46
| Facility | | $453.67 | $610.13 | $875.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.13 / $875.46 / $1,231.77
| Professional | | $283.13 | $875.46 | $1,231.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $934.96 / $1,060.82 / $1,150.71
| Professional | | $934.96 | $1,060.82 | $1,150.71 |