- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $333.50 / $333.50 / $333.50
| Facility | | $333.50 | $333.50 | $333.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.58 / $256.04 / $333.50
| Professional | | $254.58 | $256.04 | $333.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $684.13 / $684.13 / $684.13
| Professional | | $684.13 | $684.13 | $684.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $254.58 / $316.55 / $378.94
| Facility | | $254.58 | $316.55 | $378.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.54 / $1,819.54 / $1,819.54
| Professional | | $1,819.54 | $1,819.54 | $1,819.54 |