- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.68 / $426.68 / $426.68
| Facility | | $426.68 | $426.68 | $426.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.68 / $426.68 / $426.68
| Professional | | $426.68 | $426.68 | $426.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.46 / $446.47 / $1,298.53
| Professional | | $436.46 | $446.47 | $1,298.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $990.47 / $990.47 / $990.47
| Professional | | $990.47 | $990.47 | $990.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.32 / $808.85 / $1,275.08
| Professional | | $411.32 | $808.85 | $1,275.08 |