- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $681.60 / $681.60 / $681.60
| Facility | | $681.60 | $681.60 | $681.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.18 / $681.60 / $681.60
| Professional | | $346.18 | $681.60 | $681.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $451.71 / $451.71 / $955.47
| Facility | | $451.71 | $451.71 | $955.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $383.95 / $451.70 / $836.64
| Professional | | $383.95 | $451.70 | $836.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.72 / $404.52 / $561.04
| Professional | | $242.72 | $404.52 | $561.04 |