- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.42 / $508.42 / $794.98
| Professional | | $508.42 | $508.42 | $794.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $886.61 / $886.61 / $886.61
| Facility | | $886.61 | $886.61 | $886.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.61 / $886.61 / $886.61
| Professional | | $886.61 | $886.61 | $886.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.34 / $524.34 / $964.63
| Facility | | $524.34 | $524.34 | $964.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $382.77 / $382.77 / $524.34
| Professional | | $382.77 | $382.77 | $524.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $378.37 / $418.64 / $464.77
| Professional | | $378.37 | $418.64 | $464.77 |