- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $573.46 / $573.46 / $573.46
| Professional | | $573.46 | $573.46 | $573.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $878.61 / $1,120.41 / $1,535.72
| Facility | | $878.61 | $1,120.41 | $1,535.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $464.55 / $464.55 / $464.55
| Facility | | $464.55 | $464.55 | $464.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $413.66 / $413.66 / $413.66
| Professional | | $413.66 | $413.66 | $413.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $553.10 / $553.10 / $553.10
| Professional | | $553.10 | $553.10 | $553.10 |