- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $762.88 / $762.88 / $762.88
| Facility | | $762.88 | $762.88 | $762.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $726.98 / $762.88 / $762.88
| Professional | | $726.98 | $762.88 | $762.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $762.88 / $762.88 / $762.88
| Facility | | $762.88 | $762.88 | $762.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $732.40 / $762.88 / $762.88
| Professional | | $732.40 | $762.88 | $762.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,697.88 / $1,997.50 / $1,997.50
| Professional | | $1,697.88 | $1,997.50 | $1,997.50 |