- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $588.84
| Professional | | $575.44 | $575.44 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $891.25
| Facility | | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $891.25
| Professional | | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $363.08 / $891.25
| Professional | | $363.08 | $363.08 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.74 / $724.44 / $933.25
| Facility | | $467.74 | $724.44 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $588.84 / $691.83
| Professional | | $467.74 | $588.84 | $691.83 |