- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.26 / $489.26 / $489.26
| Facility | | $489.26 | $489.26 | $489.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $460.48 / $489.26 / $489.26
| Professional | | $460.48 | $489.26 | $489.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.43 / $508.43 / $508.43
| Professional | | $508.43 | $508.43 | $508.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.43 / $508.43 / $508.43
| Facility | | $508.43 | $508.43 | $508.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.43 / $508.43 / $647.53
| Professional | | $508.43 | $508.43 | $647.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $569.84 / $640.76 / $847.29
| Professional | | $569.84 | $640.76 | $847.29 |