- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $438.83 / $438.83 / $438.83
| Facility | | $438.83 | $438.83 | $438.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $395.72 / $438.83 / $868.37
| Professional | | $395.72 | $438.83 | $868.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.50 / $272.50 / $272.50
| Professional | | $272.50 | $272.50 | $272.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.70 / $206.72 / $480.51
| Professional | | $172.70 | $206.72 | $480.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $593.59 / $885.10 / $1,765.17
| Professional | | $593.59 | $885.10 | $1,765.17 |