- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.84 / $575.44 / $575.44
| Facility | | $281.84 | $575.44 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $758.58
| Professional | | $575.44 | $575.44 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $812.83 / $812.83
| Professional | | $251.19 | $812.83 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $602.56 / $1,202.26
| Facility | | $575.44 | $602.56 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Professional | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $707.95 / $707.95
| Professional | | $707.95 | $707.95 | $707.95 |