- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $913.50 / $913.50 / $1,261.50
| Facility | | $913.50 | $913.50 | $1,261.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $435.00 / $862.75 / $913.50
| Professional | | $435.00 | $862.75 | $913.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $471.25 / $546.65 / $1,300.65
| Facility | | $471.25 | $546.65 | $1,300.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $652.50 / $652.50 / $652.50
| Facility | | $652.50 | $652.50 | $652.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $304.50 / $435.00 / $725.00
| Professional | | $304.50 | $435.00 | $725.00 |