- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $409.52 / $422.89 / $422.89
| Facility | | $409.52 | $422.89 | $422.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.89 / $422.89 / $507.47
| Professional | | $422.89 | $422.89 | $507.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.41 / $257.77 / $346.78
| Facility | | $212.41 | $257.77 | $346.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $422.89 / $422.89 / $422.89
| Facility | | $422.89 | $422.89 | $422.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.89 / $422.89 / $529.26
| Professional | | $422.89 | $422.89 | $529.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $359.46 / $422.89 / $465.18
| Professional | | $359.46 | $422.89 | $465.18 |