- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $388.83 / $388.83 / $388.83
| Facility | | $388.83 | $388.83 | $388.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $392.63 / $392.63 / $431.89
| Professional | | $392.63 | $392.63 | $431.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $391.13 / $460.15 / $460.15
| Professional | | $391.13 | $460.15 | $460.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $370.40 / $370.40 / $370.40
| Facility | | $370.40 | $370.40 | $370.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $392.63 / $481.53 / $555.61
| Professional | | $392.63 | $481.53 | $555.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $392.63 / $392.63 / $392.63
| Professional | | $392.63 | $392.63 | $392.63 |