- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $460.17 / $460.17 / $460.17
| Facility | | $460.17 | $460.17 | $460.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.71 / $460.17 / $460.17
| Professional | | $233.71 | $460.17 | $460.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.44 / $407.44 / $407.44
| Professional | | $407.44 | $407.44 | $407.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $388.32 / $388.32 / $544.46
| Facility | | $388.32 | $388.32 | $544.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.07 / $388.32 / $521.04
| Professional | | $330.07 | $388.32 | $521.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.81 / $273.10 / $375.97
| Professional | | $161.81 | $273.10 | $375.97 |