- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $524.81 / $524.81
| Facility | | $524.81 | $524.81 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $524.81 / $588.84
| Professional | | $524.81 | $524.81 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $524.81 / $891.25
| Facility | | $489.78 | $524.81 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $2,344.23 / $2,344.23
| Professional | | $524.81 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $524.81 / $524.81
| Facility | | $524.81 | $524.81 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $524.81 / $891.25
| Professional | | $512.86 | $524.81 | $891.25 |