- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.02 / $529.26 / $529.26
| Facility | | $524.02 | $529.26 | $529.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.25 / $529.26 / $555.72
| Professional | | $529.25 | $529.26 | $555.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.41 / $257.77 / $346.78
| Facility | | $212.41 | $257.77 | $346.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.26 / $529.26 / $529.26
| Professional | | $529.26 | $529.26 | $529.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $529.26 / $529.26 / $529.26
| Facility | | $529.26 | $529.26 | $529.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.26 / $529.26 / $1,040.50
| Professional | | $529.26 | $529.26 | $1,040.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.26 / $529.26 / $529.26
| Professional | | $529.26 | $529.26 | $529.26 |