- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $461.36 / $461.36 / $461.36
| Facility | | $461.36 | $461.36 | $461.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.36 / $461.36 / $461.36
| Professional | | $461.36 | $461.36 | $461.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.60 / $241.60 / $241.60
| Professional | | $241.60 | $241.60 | $241.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $435.24 / $435.24 / $461.36
| Facility | | $435.24 | $435.24 | $461.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.36 / $461.36 / $587.57
| Professional | | $461.36 | $461.36 | $587.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $392.16 / $392.16 / $1,500.50
| Professional | | $392.16 | $392.16 | $1,500.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $459.21 / $461.36 / $747.76
| Professional | | $459.21 | $461.36 | $747.76 |