- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $590.77 / $590.77 / $590.77
| Facility | | $590.77 | $590.77 | $590.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $590.77 / $590.77 / $590.77
| Professional | | $590.77 | $590.77 | $590.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $590.77 / $590.77 / $590.77
| Facility | | $590.77 | $590.77 | $590.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $366.69 / $366.69 / $590.77
| Professional | | $366.69 | $366.69 | $590.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.54 / $103.54 / $246.52
| Professional | | $103.54 | $103.54 | $246.52 |