- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $514.92 / $514.92 / $514.92
| Facility | | $514.92 | $514.92 | $514.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.52 / $514.92 / $514.92
| Professional | | $261.52 | $514.92 | $514.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $414.32 / $414.32 / $414.32
| Professional | | $414.32 | $414.32 | $414.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $401.27 / $401.27 / $609.27
| Facility | | $401.27 | $401.27 | $609.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $292.93 / $401.27 / $533.50
| Professional | | $292.93 | $401.27 | $533.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.02 / $305.60 / $420.71
| Professional | | $181.02 | $305.60 | $420.71 |