- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $426.58 / $512.86
| Facility | | $426.58 | $426.58 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $371.54 / $512.86
| Professional | | $316.23 | $371.54 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,445.44 / $2,290.87
| Facility | | $724.44 | $1,445.44 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,148.15 / $1,202.26
| Professional | | $676.08 | $1,148.15 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,148.15 / $1,202.26
| Professional | | $794.33 | $1,148.15 | $1,202.26 |