- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $691.83
| Professional | | $575.44 | $575.44 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $602.56
| Facility | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $602.56
| Professional | | $575.44 | $575.44 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $346.74 / $1,148.15
| Facility | | $295.12 | $346.74 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $346.74 / $1,148.15
| Professional | | $295.12 | $346.74 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $602.56
| Facility | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $602.56 / $812.83
| Professional | | $79.43 | $602.56 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $575.44
| Professional | | $575.44 | $575.44 | $575.44 |