- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $184.71 / $184.71 / $184.71
| Facility | | $184.71 | $184.71 | $184.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.71 / $184.71 / $184.71
| Professional | | $184.71 | $184.71 | $184.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $570.65 / $570.65 / $570.65
| Professional | | $570.65 | $570.65 | $570.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $570.54 / $570.54 / $570.54
| Facility | | $570.54 | $570.54 | $570.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.23 / $356.23 / $356.23
| Professional | | $356.23 | $356.23 | $356.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $587.76 / $645.89 / $1,046.84
| Professional | | $587.76 | $645.89 | $1,046.84 |