- 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 / $954.99
| Professional | | $562.34 | $562.34 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $660.69 / $660.69
| Professional | | $562.34 | $660.69 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $524.81 / $524.81
| Facility | | $524.81 | $524.81 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $794.33
| Professional | | $562.34 | $562.34 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $1,096.48
| Facility | | $562.34 | $562.34 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $562.34
| Professional | | $562.34 | $562.34 | $562.34 |