- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $529.38 / $529.38 / $529.38
| Facility | | $529.38 | $529.38 | $529.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.38 / $529.38 / $546.29
| Professional | | $529.38 | $529.38 | $546.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.65 / $1,037.23 / $1,037.23
| Professional | | $881.65 | $1,037.23 | $1,037.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $515.37 / $515.37 / $515.37
| Facility | | $515.37 | $515.37 | $515.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $546.29 / $546.29 / $773.06
| Professional | | $546.29 | $546.29 | $773.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $546.29 / $546.29 / $546.29
| Professional | | $546.29 | $546.29 | $546.29 |