- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $593.54 / $615.26 / $615.26
| Professional | | $593.54 | $615.26 | $615.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $579.07 / $651.46 / $660.51
| Professional | | $579.07 | $651.46 | $660.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $615.26 / $615.26 / $615.26
| Facility | | $615.26 | $615.26 | $615.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.26 / $615.26 / $615.26
| Professional | | $615.26 | $615.26 | $615.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.26 / $615.26 / $615.26
| Professional | | $615.26 | $615.26 | $615.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.26 / $615.26 / $615.26
| Professional | | $615.26 | $615.26 | $615.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.26 / $723.84 / $1,049.57
| Professional | | $615.26 | $723.84 | $1,049.57 |