- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.46 / $508.46 / $508.46
| Facility | | $508.46 | $508.46 | $508.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.46 / $508.46 / $508.46
| Professional | | $508.46 | $508.46 | $508.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $612.60 / $612.60 / $612.60
| Facility | | $612.60 | $612.60 | $612.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.71 / $520.71 / $520.71
| Professional | | $520.71 | $520.71 | $520.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $520.71 / $520.71 / $1,452.09
| Facility | | $520.71 | $520.71 | $1,452.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $484.98 / $510.50 / $510.50
| Professional | | $484.98 | $510.50 | $510.50 |