- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $583.28 / $583.28 / $583.28
| Facility | | $583.28 | $583.28 | $583.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.24 / $583.28 / $583.28
| Professional | | $296.24 | $583.28 | $583.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $516.44 / $516.44 / $516.44
| Professional | | $516.44 | $516.44 | $516.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $500.58 / $500.58 / $773.83
| Facility | | $500.58 | $500.58 | $773.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $365.42 / $500.58 / $677.59
| Professional | | $365.42 | $500.58 | $677.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.78 / $346.16 / $533.42
| Professional | | $230.78 | $346.16 | $533.42 |