- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $558.46 / $558.46 / $959.61
| Professional | | $558.46 | $558.46 | $959.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $632.21 / $632.21 / $632.21
| Facility | | $632.21 | $632.21 | $632.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $526.85 / $614.23 / $1,023.72
| Facility | | $526.85 | $614.23 | $1,023.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $558.46 / $558.46 / $558.46
| Professional | | $558.46 | $558.46 | $558.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $526.85 / $614.23 / $1,023.72
| Facility | | $526.85 | $614.23 | $1,023.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $558.46 / $558.46 / $558.46
| Professional | | $558.46 | $558.46 | $558.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $536.55 / $558.46 / $591.97
| Professional | | $536.55 | $558.46 | $591.97 |