- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $578.91 / $578.91 / $578.91
| Facility | | $578.91 | $578.91 | $578.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $397.69 / $417.82 / $417.82
| Professional | | $397.69 | $417.82 | $417.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $327.20 / $327.20 / $327.20
| Facility | | $327.20 | $327.20 | $327.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.00 / $525.00 / $656.25
| Professional | | $525.00 | $525.00 | $656.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.19 / $241.63 / $503.40
| Professional | | $176.19 | $241.63 | $503.40 |