- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $616.60
| Facility | | $616.60 | $616.60 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $616.60
| Professional | | $616.60 | $616.60 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $602.56 / $1,071.52
| Professional | | $426.58 | $602.56 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $489.78 / $758.58
| Professional | | $467.74 | $489.78 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $426.58 / $426.58
| Facility | | $363.08 | $426.58 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $426.58 / $1,071.52
| Professional | | $257.04 | $426.58 | $1,071.52 |