- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $547.63 / $547.63 / $547.63
| Facility | | $547.63 | $547.63 | $547.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $404.35 / $547.63 / $547.63
| Professional | | $404.35 | $547.63 | $547.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.51 / $548.47 / $673.49
| Professional | | $328.51 | $548.47 | $673.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.80 / $673.49 / $673.49
| Professional | | $189.80 | $673.49 | $673.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.34 / $699.03 / $1,044.42
| Professional | | $354.34 | $699.03 | $1,044.42 |