- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $577.50 / $577.50 / $577.50
| Facility | | $577.50 | $577.50 | $577.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.80 / $397.78 / $577.50
| Professional | | $346.80 | $397.78 | $577.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $648.23 / $786.65 / $1,058.30
| Facility | | $648.23 | $786.65 | $1,058.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.58 / $372.26 / $439.27
| Professional | | $260.58 | $372.26 | $439.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $276.35 / $344.21 / $524.52
| Professional | | $276.35 | $344.21 | $524.52 |