- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $875.37 / $875.37 / $875.37
| Facility | | $875.37 | $875.37 | $875.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $656.95 / $875.37 / $875.37
| Professional | | $656.95 | $875.37 | $875.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $574.29 / $892.42 / $1,095.85
| Professional | | $574.29 | $892.42 | $1,095.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.16 / $1,095.85 / $1,095.85
| Professional | | $364.16 | $1,095.85 | $1,095.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $679.85 / $1,117.33 / $1,976.38
| Professional | | $679.85 | $1,117.33 | $1,976.38 |