- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $446.68 / $446.68
| Facility | | $446.68 | $446.68 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $446.68 / $446.68
| Professional | | $446.68 | $446.68 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,479.11
| Facility | | $1,288.25 | $1,288.25 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $933.25
| Professional | | $741.31 | $741.31 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $446.68 / $794.33
| Facility | | $446.68 | $446.68 | $794.33 |