- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.67 / $741.67 / $741.67
| Facility | | $741.67 | $741.67 | $741.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.68 / $741.67 / $741.67
| Professional | | $376.68 | $741.67 | $741.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $656.68 / $656.68 / $656.68
| Professional | | $656.68 | $656.68 | $656.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $624.54 / $624.54 / $877.53
| Facility | | $624.54 | $624.54 | $877.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $455.91 / $624.54 / $839.78
| Professional | | $455.91 | $624.54 | $839.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.73 / $440.17 / $630.37
| Professional | | $260.73 | $440.17 | $630.37 |