- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $336.13 / $380.95 / $488.92
| Facility | | $336.13 | $380.95 | $488.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.72 / $87.72 / $87.72
| Professional | | $87.72 | $87.72 | $87.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $488.92 / $488.92 / $488.92
| Professional | | $488.92 | $488.92 | $488.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $403.16 / $483.41 / $534.75
| Professional | | $403.16 | $483.41 | $534.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $448.17 / $488.92 / $570.40
| Professional | | $448.17 | $488.92 | $570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.51 / $248.27 / $488.92
| Professional | | $165.51 | $248.27 | $488.92 |