- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $535.16 / $535.16 / $535.16
| Facility | | $535.16 | $535.16 | $535.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.36 / $507.49 / $576.69
| Professional | | $461.36 | $507.49 | $576.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $461.36 / $688.14 / $791.36
| Facility | | $461.36 | $688.14 | $791.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.36 / $461.36 / $461.36
| Professional | | $461.36 | $461.36 | $461.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.36 / $461.36 / $461.36
| Professional | | $461.36 | $461.36 | $461.36 |