- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $663.63 / $663.63 / $663.63
| Professional | | $663.63 | $663.63 | $663.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $626.05 / $814.38 / $1,357.30
| Facility | | $626.05 | $814.38 | $1,357.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $663.63 / $663.63 / $1,357.30
| Professional | | $663.63 | $663.63 | $1,357.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $626.05 / $814.38 / $1,357.30
| Facility | | $626.05 | $814.38 | $1,357.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $663.63 / $663.63 / $1,357.30
| Professional | | $663.63 | $663.63 | $1,357.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $663.63 / $663.63 / $1,990.89
| Professional | | $663.63 | $663.63 | $1,990.89 |