- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $562.34
| Facility | | $562.34 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $616.60
| Professional | | $562.34 | $562.34 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $562.34 / $812.83
| Facility | | $524.81 | $562.34 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $2,344.23 / $2,344.23
| Professional | | $562.34 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $562.34
| Facility | | $562.34 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $562.34 / $645.65
| Professional | | $537.03 | $562.34 | $645.65 |