- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $528.60 / $599.08 / $768.88
| Facility | | $528.60 | $599.08 | $768.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $768.88 / $768.88 / $768.88
| Professional | | $768.88 | $768.88 | $768.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $570.28 / $670.92 / $800.91
| Professional | | $570.28 | $670.92 | $800.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $640.73 / $768.88 / $961.10
| Professional | | $640.73 | $768.88 | $961.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.11 / $768.88 / $961.10
| Professional | | $269.11 | $768.88 | $961.10 |