- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $359.59 / $359.59 / $359.59
| Facility | | $359.59 | $359.59 | $359.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $359.59 / $880.56 / $1,288.74
| Professional | | $359.59 | $880.56 | $1,288.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.63 / $359.59 / $1,077.26
| Facility | | $346.63 | $359.59 | $1,077.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $359.59 / $370.38 / $1,288.74
| Professional | | $359.59 | $370.38 | $1,288.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $498.35 / $530.74 / $884.56
| Professional | | $498.35 | $530.74 | $884.56 |