- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.50 / $1,130.68 / $1,155.95
| Facility | | $575.50 | $1,130.68 | $1,155.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.50 / $575.50 / $690.60
| Professional | | $575.50 | $575.50 | $690.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.53 / $580.72 / $781.26
| Facility | | $478.53 | $580.72 | $781.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.50 / $575.50 / $575.50
| Professional | | $575.50 | $575.50 | $575.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.50 / $575.50 / $575.50
| Facility | | $575.50 | $575.50 | $575.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.50 / $575.50 / $575.50
| Professional | | $575.50 | $575.50 | $575.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $460.40 / $575.50 / $610.03
| Professional | | $460.40 | $575.50 | $610.03 |