- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $784.36 / $784.36 / $784.36
| Facility | | $784.36 | $784.36 | $784.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $305.20 / $331.17 / $351.29
| Professional | | $305.20 | $331.17 | $351.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $451.71 / $451.71 / $451.71
| Facility | | $451.71 | $451.71 | $451.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $383.95 / $383.95 / $451.71
| Professional | | $383.95 | $383.95 | $451.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $334.05 / $369.97 / $548.44
| Professional | | $334.05 | $369.97 | $548.44 |