- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $461.62 / $461.62 / $461.62
| Facility | | $461.62 | $461.62 | $461.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.62 / $461.62 / $461.62
| Professional | | $461.62 | $461.62 | $461.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $479.72 / $479.72 / $479.72
| Professional | | $479.72 | $479.72 | $479.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $506.88 / $506.88 / $506.88
| Facility | | $506.88 | $506.88 | $506.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.13 / $975.13 / $975.13
| Professional | | $975.13 | $975.13 | $975.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $448.04 / $511.40 / $651.70
| Professional | | $448.04 | $511.40 | $651.70 |