- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $735.05 / $735.05 / $735.05
| Professional | | $735.05 | $735.05 | $735.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $693.44 / $1,058.52 / $1,764.19
| Facility | | $693.44 | $1,058.52 | $1,764.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $735.05 / $735.05 / $1,764.19
| Professional | | $735.05 | $735.05 | $1,764.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $693.44 / $1,058.52 / $1,764.19
| Facility | | $693.44 | $1,058.52 | $1,764.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $735.05 / $735.05 / $1,764.19
| Professional | | $735.05 | $735.05 | $1,764.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $735.05 / $735.05 / $2,205.15
| Professional | | $735.05 | $735.05 | $2,205.15 |