- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $759.40 / $759.40 / $1,048.70
| Facility | | $759.40 | $759.40 | $1,048.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $361.62 / $717.21 / $759.40
| Professional | | $361.62 | $717.21 | $759.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $391.76 / $454.44 / $1,081.26
| Facility | | $391.76 | $454.44 | $1,081.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $542.42 / $542.42 / $542.42
| Facility | | $542.42 | $542.42 | $542.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.13 / $361.62 / $602.70
| Professional | | $253.13 | $361.62 | $602.70 |