- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $575.44
| Professional | | $575.44 | $575.44 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $691.83 / $758.58
| Professional | | $616.60 | $691.83 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $1,584.89
| Facility | | $602.56 | $602.56 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $588.84
| Professional | | $549.54 | $549.54 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $562.34
| Facility | | $562.34 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $588.84 / $776.25
| Professional | | $380.19 | $588.84 | $776.25 |