- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $669.68 / $669.68 / $772.70
| Professional | | $669.68 | $669.68 | $772.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $907.46 / $907.46 / $907.46
| Facility | | $907.46 | $907.46 | $907.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $662.45 / $1,054.94 / $1,124.17
| Professional | | $662.45 | $1,054.94 | $1,124.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $907.46 / $907.46 / $907.46
| Facility | | $907.46 | $907.46 | $907.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $662.45 / $1,055.84 / $1,124.17
| Professional | | $662.45 | $1,055.84 | $1,124.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.42 / $812.91 / $1,586.46
| Professional | | $456.42 | $812.91 | $1,586.46 |