- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.73 / $457.73 / $457.73
| Facility | | $457.73 | $457.73 | $457.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.73 / $457.73 / $457.73
| Professional | | $457.73 | $457.73 | $457.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $518.17 / $518.17 / $1,313.95
| Facility | | $518.17 | $518.17 | $1,313.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.17 / $518.17 / $518.17
| Professional | | $518.17 | $518.17 | $518.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.17 / $518.17 / $518.17
| Professional | | $518.17 | $518.17 | $518.17 |