- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $602.56 / $602.56
| Facility | | $478.63 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $512.86 / $602.56
| Professional | | $478.63 | $512.86 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $1,122.02
| Facility | | $512.86 | $512.86 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $512.86
| Professional | | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $602.56 / $1,348.96
| Facility | | $478.63 | $602.56 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $2,290.87
| Professional | | $501.19 | $501.19 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $524.81 / $602.56
| Facility | | $501.19 | $524.81 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $501.19
| Professional | | $501.19 | $501.19 | $501.19 |