- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $473.03 / $473.03 / $473.03
| Facility | | $473.03 | $473.03 | $473.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.24 / $473.03 / $473.03
| Professional | | $240.24 | $473.03 | $473.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $418.83 / $418.83 / $418.83
| Professional | | $418.83 | $418.83 | $418.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $362.03 / $362.03 / $559.66
| Facility | | $362.03 | $362.03 | $559.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.27 / $362.03 / $490.06
| Professional | | $264.27 | $362.03 | $490.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.28 / $280.73 / $386.48
| Professional | | $166.28 | $280.73 | $386.48 |