- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.50 / $575.50 / $1,041.71
| Professional | | $575.50 | $575.50 | $1,041.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $651.51 / $651.51 / $651.51
| Facility | | $651.51 | $651.51 | $651.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $542.92 / $716.46 / $1,188.84
| Facility | | $542.92 | $716.46 | $1,188.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.50 / $575.50 / $1,188.84
| Professional | | $575.50 | $575.50 | $1,188.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $542.92 / $716.46 / $1,188.84
| Facility | | $542.92 | $716.46 | $1,188.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.50 / $575.50 / $1,188.84
| Professional | | $575.50 | $575.50 | $1,188.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $365.85 / $610.03 / $1,329.64
| Professional | | $365.85 | $610.03 | $1,329.64 |