- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.96 / $675.38 / $1,103.98
| Facility | | $508.96 | $675.38 | $1,103.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.96 / $508.96 / $628.62
| Professional | | $508.96 | $508.96 | $628.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $576.48 / $576.48 / $576.48
| Professional | | $576.48 | $576.48 | $576.48 |
- 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 / $508.96
| Professional | | $508.96 | $508.96 | $508.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $662.04 / $2,488.50 / $2,544.80
| Facility | | $662.04 | $2,488.50 | $2,544.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.96 / $508.96 / $513.98
| Professional | | $508.96 | $508.96 | $513.98 |