- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $426.58 / $426.58
| Facility | | $426.58 | $426.58 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $426.58 / $602.56
| Professional | | $371.54 | $426.58 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $776.25
| Professional | | $616.60 | $616.60 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $426.58 / $426.58
| Facility | | $426.58 | $426.58 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $426.58 / $707.95
| Professional | | $398.11 | $426.58 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.84 / $371.54 / $977.24
| Facility | | $281.84 | $371.54 | $977.24 |