- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $327.43 / $327.43 / $327.43
| Facility | | $327.43 | $327.43 | $327.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.43 / $327.43 / $390.48
| Professional | | $327.43 | $327.43 | $390.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $462.77 / $517.53 / $517.53
| Facility | | $462.77 | $517.53 | $517.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.31 / $310.31 / $310.31
| Professional | | $310.31 | $310.31 | $310.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $327.43 / $507.52 / $622.12
| Facility | | $327.43 | $507.52 | $622.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $666.55 / $666.55 / $666.55
| Facility | | $666.55 | $666.55 | $666.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $590.29 / $632.52 / $632.52
| Professional | | $590.29 | $632.52 | $632.52 |