- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.96 / $508.96 / $519.52
| Facility | | $508.96 | $508.96 | $519.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.96 / $508.96 / $893.58
| Professional | | $508.96 | $508.96 | $893.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,177.97 / $1,429.52 / $1,923.16
| Facility | | $1,177.97 | $1,429.52 | $1,923.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.96 / $508.96 / $508.96
| Professional | | $508.96 | $508.96 | $508.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.96 / $508.96 / $508.96
| Facility | | $508.96 | $508.96 | $508.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.96 / $508.96 / $827.91
| Professional | | $508.96 | $508.96 | $827.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.96 / $508.96 / $508.96
| Professional | | $508.96 | $508.96 | $508.96 |