- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $725.00 / $1,326.75 / $1,791.11
| Facility | | $725.00 | $1,326.75 | $1,791.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $572.75 / $572.75 / $572.75
| Professional | | $572.75 | $572.75 | $572.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $942.50 / $978.75 / $978.75
| Facility | | $942.50 | $978.75 | $978.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $471.25 / $471.25 / $494.81
| Facility | | $471.25 | $471.25 | $494.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $304.50 / $435.00 / $1,237.55
| Professional | | $304.50 | $435.00 | $1,237.55 |