- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $582.63 / $582.63 / $582.63
| Facility | | $582.63 | $582.63 | $582.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $582.63 / $597.02
| Professional | | $575.44 | $582.63 | $597.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $611.41 / $611.41 / $611.41
| Facility | | $611.41 | $611.41 | $611.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $611.41 / $611.41 / $611.41
| Professional | | $611.41 | $611.41 | $611.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $582.63 / $664.20 / $1,322.47
| Facility | | $582.63 | $664.20 | $1,322.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $683.34 / $683.34 / $841.24
| Professional | | $683.34 | $683.34 | $841.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $683.34 / $683.34 / $732.27
| Professional | | $683.34 | $683.34 | $732.27 |