- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $526.44 / $526.44 / $526.44
| Facility | | $526.44 | $526.44 | $526.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $391.60 / $507.29 / $526.44
| Professional | | $391.60 | $507.29 | $526.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.77 / $562.12 / $690.30
| Professional | | $346.77 | $562.12 | $690.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.80 / $690.30 / $690.30
| Professional | | $189.80 | $690.30 | $690.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.34 / $671.96 / $1,042.38
| Professional | | $354.34 | $671.96 | $1,042.38 |