- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $446.68 / $446.68
| Facility | | $446.68 | $446.68 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $446.68 / $562.34
| Professional | | $446.68 | $446.68 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $676.08 / $1,071.52
| Facility | | $537.03 | $676.08 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $707.95 / $977.24
| Professional | | $676.08 | $707.95 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $1,071.52 / $1,071.52
| Professional | | $537.03 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $575.44 / $1,202.26
| Professional | | $416.87 | $575.44 | $1,202.26 |