- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $512.86
| Facility | | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $501.19 / $512.86
| Professional | | $478.63 | $501.19 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $954.99 / $954.99
| Facility | | $512.86 | $954.99 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $2,691.53
| Professional | | $512.86 | $512.86 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $562.34
| Facility | | $562.34 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $602.56
| Professional | | $501.19 | $501.19 | $602.56 |