- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $415.31 / $470.68 / $604.08
| Facility | | $415.31 | $470.68 | $604.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.08 / $604.08 / $604.08
| Professional | | $604.08 | $604.08 | $604.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $448.05 / $527.12 / $629.25
| Professional | | $448.05 | $527.12 | $629.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.40 / $604.08 / $755.10
| Professional | | $503.40 | $604.08 | $755.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.43 / $604.08 / $755.10
| Professional | | $211.43 | $604.08 | $755.10 |