- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $475.20 / $475.20 / $475.20
| Facility | | $475.20 | $475.20 | $475.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.36 / $475.20 / $475.20
| Professional | | $461.36 | $475.20 | $475.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.36 / $461.36 / $567.22
| Professional | | $461.36 | $461.36 | $567.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $461.36 / $461.36 / $475.20
| Facility | | $461.36 | $461.36 | $475.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.36 / $461.36 / $604.98
| Professional | | $461.36 | $461.36 | $604.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.31 / $551.70 / $752.32
| Professional | | $330.31 | $551.70 | $752.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.36 / $461.36 / $553.63
| Professional | | $461.36 | $461.36 | $553.63 |