- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $520.71 / $520.71 / $520.71
| Facility | | $520.71 | $520.71 | $520.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.46 / $508.46 / $520.71
| Professional | | $508.46 | $508.46 | $520.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $510.50 / $510.50 / $510.50
| Facility | | $510.50 | $510.50 | $510.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $510.50 / $510.50 / $510.50
| Professional | | $510.50 | $510.50 | $510.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $520.71 / $520.71 / $520.71
| Facility | | $520.71 | $520.71 | $520.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.71 / $520.71 / $520.71
| Professional | | $520.71 | $520.71 | $520.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $510.50 / $510.50 / $520.71
| Professional | | $510.50 | $510.50 | $520.71 |