- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.77 / $724.77 / $724.77
| Facility | | $724.77 | $724.77 | $724.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.77 / $724.77 / $724.77
| Professional | | $724.77 | $724.77 | $724.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $682.14 / $682.14 / $682.14
| Professional | | $682.14 | $682.14 | $682.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.77 / $724.77 / $724.77
| Facility | | $724.77 | $724.77 | $724.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $646.61 / $710.56 / $1,151.66
| Professional | | $646.61 | $710.56 | $1,151.66 |