- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.78 / $416.78 / $416.78
| Facility | | $416.78 | $416.78 | $416.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.78 / $416.78 / $416.79
| Professional | | $416.78 | $416.78 | $416.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $472.09 / $506.12 / $581.38
| Facility | | $472.09 | $506.12 | $581.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.78 / $416.78 / $416.78
| Professional | | $416.78 | $416.78 | $416.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.53 / $439.90 / $1,875.51
| Professional | | $183.53 | $439.90 | $1,875.51 |