- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $656.12 / $656.12 / $656.12
| Professional | | $656.12 | $656.12 | $656.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $618.98 / $1,166.20 / $1,462.86
| Facility | | $618.98 | $1,166.20 | $1,462.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $656.12 / $656.12 / $1,462.86
| Professional | | $656.12 | $656.12 | $1,462.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $618.98 / $1,166.20 / $1,462.86
| Facility | | $618.98 | $1,166.20 | $1,462.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $656.12 / $656.12 / $1,462.86
| Professional | | $656.12 | $656.12 | $1,462.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $656.12 / $656.12 / $1,968.36
| Professional | | $656.12 | $656.12 | $1,968.36 |