- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $503.65 / $503.65 / $503.65
| Facility | | $503.65 | $503.65 | $503.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.65 / $503.65 / $503.65
| Professional | | $503.65 | $503.65 | $503.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $686.96 / $686.96 / $841.22
| Professional | | $686.96 | $686.96 | $841.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.58 / $541.58 / $541.58
| Professional | | $541.58 | $541.58 | $541.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $799.88 / $799.88 / $2,442.78
| Professional | | $799.88 | $799.88 | $2,442.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $409.28 / $613.91 / $1,291.33
| Professional | | $409.28 | $613.91 | $1,291.33 |