- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $588.84 / $588.84
| Facility | | $588.84 | $588.84 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $630.96
| Professional | | $575.44 | $575.44 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $575.44 / $851.14
| Facility | | $549.54 | $575.44 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $2,454.71 / $2,454.71
| Professional | | $575.44 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $575.44
| Facility | | $575.44 | $575.44 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $575.44 / $691.83
| Professional | | $562.34 | $575.44 | $691.83 |